Complex renal cyst. Laparoscopic treatment

The difference between the simple renal cysts, that doesn't require surgical treatment, and those that need it, sometimes is difficult. The laparoscopic surgical treatment (laparoscopic cyst decortication -laparoscopic partial nefrectomy or radical laparoscopic nefrectomy) its becoming the gold standard technique, recommending this procedure in Bosniak cyst type III or IV, and in the symptomatic renal cyst type I/II and in any patients with Bosniak cyst renal II. We present a case report in which a renal cell carcinoma was found after laparoscopic cyst decortication of Bosniak cyst type II with laparoscopic radical nefrectomy posteriorly.     

Surgical Management of Renal Cystic Disease

The kidney is one of the most common sites for cyst in the body (prevalence about 5%). Symptomatic or incidental cyst needs to be characterized further based on Bosniak classification as simple (Bosniak type I & II) or complex (Bosniak type III & IV) cysts with respect to risk of malignancy or other effects on the kidney. The management of simple cysts is entirely for its symptoms or complications (eg, hemorrhage, infection, hydronephrosis, and hypertension). Percutaneous aspiration alone or with sclerotherapy often is the first-line treatment. Surgical decortication generally is reserved for recurrent or very large symptomatic cysts. Laparoscopic surgery is highly efficacious and is associated with high satisfaction rates with minimal morbidity. Retroperitoneal approach is generally preferred, especially in infected or hydatid renal cyst to avoid spillage or contamination of virgin peritoneal cavity. Cyst decortication seems to be an appropriate indication for newer-emerging single-port laparoscopic approaches such as natural orifice transluminal endoscopic surgery, single-incision laparoscopic surgery, or laparoendoscopic single-site surgery. Where available, robot-assisted surgical management can supplant pure laparoscopic management for complex cysts, hydatid cyst, peripelvic cyst, and autosomal dominant polycystic kidney disease without any outstanding benefits, but with added cost, when robot is used.     

Laparoscopic deroofing of a renal cyst: the hidden invasion

Cysts of the kidney usually originate from the renal parenchyma after tubule obstruction; rarely pyelocalyceal cysts occur, originating from transitional urothelium. Neoplasia is a rare but possible complication. A 45-year-old man was found to have a cyst related to the right kidney. Computed tomography demonstrated minimal calcification in the wall (Bosniak II). Symptom-relieving percutaneous drainage yielded clear fluid; resultant cytology was negative. After rapid reaccumulation, laparoscopic deroofing was performed. No communication within the renal pelvis was detected however histology revealed transitional cell carcinoma. An open radical nephroureterectomy was performed; adjuvant chemotherapy was given. Three previous cases of malignancy in a pyelocalyceal cyst have been reported. This is the first reported after laparoscopic deroofing of a cyst. Despite widespread use of the Bosniak renal cyst classification, the management of category II cysts remains contentious. This case should serve as a warning to clinicians that seemingly benign cysts of the kidney may harbor underlying neoplasia. Intraoperative frozen section should be considered in all cases where preoperative imaging suggests Bosniak II classification.     

Laparoscopic evaluation of indeterminate renal cysts: long-term follow-up

PURPOSE: We present our long-term follow-up of patients who have undergone laparoscopic evaluation for their indeterminate renal cysts, specifically reporting those patients who were found to have cystic renal-cell carcinoma (RCC) and assessing the safety and efficacy of the procedure. PATIENTS AND METHODS: Fifty-seven patients with indeterminate renal cysts (28 Bosniak category II and 29 Bosniak category III) underwent laparoscopic evaluation between July 1993 and July 2000. A transperitoneal laparoscopic localization and aspiration of the cyst, cytologic analysis, and biopsy of the cyst wall and base were performed. A total of 11 patients were found to have cystic RCC. Patients with malignancy have been followed for a mean of 40 months (range 6-70 months), and five patients had 5 years or more of follow-up. RESULTS: Eleven patients (19% of the total) were found to have cystic RCC. Three of these patients had Bosniak category II cysts, and eight had category III cysts. All tumors were low grade (I or II), and the stages were T1-2, Nx-0, M0. There has been no evidence of laparoscopic port site or renal fossa tumor recurrence, local recurrence, or metastatic disease to date in these patients. There is no cancer-specific mortality. CONCLUSIONS: Long-term follow-up indicates that laparoscopic evaluation of indeterminate renal cysts is not associated with an increased risk of port site or retroperitoneal or peritoneal recurrence of RCC. It may save a patient from undergoing open surgery and should be considered as a diagnostic option for patients with indeterminate renal cysts.     

Prevalence of renal cysts in a Middle-Eastern population: an evaluation of characteristics and risk factors

OBJECTIVE

To assess the prevalence of renal cysts in a large Middle‐Eastern population presenting for a health‐screening programme, evaluating cyst characteristics and risk factors for their development.

PATIENTS AND METHODS

The reported prevalence of renal cysts detected by ultrasonography (US) in the general population is 5.0–20.8%, and their development has been linked to several factors. The electronic charts of 8551 patients (from eight nations, predominantly Egypt and Yemen) presenting for the ‘check‐up’ programme at the author’s institution during 2005 were retrospectively reviewed. The presence and characteristics of renal cysts on abdominal US were noted, as were any associated renal pathologies. Various risk factors were evaluated for renal cyst development, i.e. age, gender, hypertension, diabetes mellitus and serum creatinine levels, and hyperlipidaemia and a history of bilharziasis were also assessed.

RESULTS

The prevalence of renal cysts was 4.2%, ranging from 0.6% for patients in their third decade, to a third of those aged >80 years. Cysts were detected in 4.8% of men and 2.8% of women (P < 0.001). The mean serum creatinine level was 1.02 mg/dL in those with cysts and 0.88 mg/dL in those without (P < 0.001). On univariate analysis, hypertension, diabetes and hyperlipidaemia had a significant influence on the occurrence of renal cysts, but not in the multivariate model. Of the 361 patients with renal cysts, 58 (16.1%) had bilateral and 26 (7.2%) had multiple unilateral cysts, with a mean (range) size of 26 (4–104) mm. The vast majority of cysts were classified as Bosniak I simple cysts; seven were Bosniak II and there was one Bosniak IV cyst. Associated renal pathologies included renal stones in 39 patients, hydronephrosis in nine, increased parenchymal echogenicity in 18, small atrophic kidneys in three, haematuria (not associated with other imaging abnormalities) in six, and a renal mass in one patient.

CONCLUSIONS

The prevalence of renal cysts detected by US in a health‐screened population from the Middle East was 4.2%. Increasing age, male gender and a higher serum creatinine level were significant independent risk factors for cyst development. There was also a relatively high prevalence of associated renal pathologies (increased parenchymal echogenicity and stones).     

A simple renal cyst invaded by infiltrating urothelial carcinoma mimicking a Bosniak Class IV renal cyst

We report a 79-year-old woman with a left side simple renal cyst invaded by infiltrating urothelial carcinoma mimicking a Bosniak Class IV renal cyst. Computerized tomography has high accuracy for the diagnosis of renal cysts and urothelail carcinoma. But, in this case it was still difficult to distinguish a simple renal cyst with infiltrating urothelial carcinoma invasion from a Bosniak Class IV renal cyst on CT scan. The management of a Bosniak Class IV renal cyst and urothelail carcinoma is totally different. Therefore, we performed a left side nephroureterectomy. This patient will have regular follow-up with cystoscopy every 3 months for the first 2 y, every 6 months for the next 2 y, and then annually thereafter.     

Category migration of renal cystic masses with use of gadolinium-enhanced magnetic resonance imaging

The Bosniak renal cyst classification has been accepted by urologists and radiologists as a way of diagnosing cystic renal masses and determining the management approach. We report two cases of a renal cystic mass that showed a category change from category II on the basis of enhanced computed tomography to category IV after further gadolinium-enhanced magnetic resonance imaging. In both cases, the cysts were later confirmed as kidney cancer by pathology.     

Laparoscopic partial nephrectomy for cystic masses

PURPOSE: Although laparoscopic partial nephrectomy (LPN) has emerged as an effective treatment option in select patients with a solid renal tumor, scant data are available on cystic renal tumors. We report our experience with LPN in 50 patients with a cystic renal lesion. MATERIALS AND METHODS: Of 284 patients undergoing LPN at our institution since August 1999 preoperative computerized tomography identified a suspicious cystic lesion in 50 (17.6%) (group 1). Data were retrospectively compared with those on 50 matched, consecutive patients undergoing LPN for a solid renal mass (group 2). All patients with Bosniak II/IIF cysts were advised to undergo watchful waiting. Surgery was offered if the cyst changed in character or if that was the patient preference. RESULTS: Median tumor size was 3 cm in group 1 and 2.6 cm in group 2 (p = 0.07). Groups 1 and 2 were comparable in regard to perioperative parameters. In patients with Bosniak II (9), IIF (4), III (12) and IV (21) cysts final histopathology revealed renal cell carcinoma in 22%, 25%, 50% and 90%, respectively. All 100 patients had a negative surgical margin. No patient in group 1 had intraoperative puncture/spillage of the cystic tumor. In group 1 during a mean followup of 14 months (range 1 month to 3 years) 1 patient had retroperitoneal recurrence at 1 year despite negative surgical margins during initial LPN. CONCLUSIONS: Surgical outcomes of LPN for suspicious cystic masses are similar to those of LPN for solid tumors. However, extreme caution and refined laparoscopic technique must be exercised to avoid cyst rupture and local spillage.     

BosniakⅡ~Ⅳ级肾囊性占位临床与病理学特点分析简

目的 探讨Bosniak Ⅱ-Ⅳ级肾囊性占位临床与病理学特点。方法 回顾性分析上海交通大学医学院附属仁济医院从2008年1月至2012年12月CT诊断为囊性肾脏占位（BosniakⅡ、ⅡF、Ⅲ、Ⅳ）的170例患者的病例资料,其中Ⅱ级囊肿73例,ⅡF级囊肿34例、Ⅲ级囊肿38例、Ⅳ级囊肿25例。男105例,女65例;年龄20-85岁,平均（56±14.2）岁;病灶位于左侧87例,右侧66例,双侧17例。80例接受手术治疗的患者中,Ⅱ级囊肿18例,ⅡF级囊肿8例,Ⅲ级囊肿30例,Ⅳ级囊肿24例;行腹腔镜肾囊肿去顶减压术25例,腹腔镜肾部分切除术15例,腹腔镜根治性肾切除术7例,开放肾癌根治术6例,开放肾部分切除术27例。其余90例进行了影像学的随访。分析不同分型囊性肾脏占位的良恶性比例、病理学特点、随访结果。结果 手术病例中Ⅱ级囊肿恶性病例为1例（5.6%）,ⅡF级1例（12.5%）,Ⅲ级16例（53.3%）,Ⅳ级21例（87.5%）,组间比较有明显统计学差异（P＜001）。术后病理结果：恶性肿瘤共39例（透明细胞癌31例,乳头状癌8例）,Fuhrman分级均为Ⅰ级。良性病例共41例（单纯囊肿26例,囊肿伴出血3例,囊肿伴感染5例,囊性肾瘤4例,错构瘤3例）。术后患者随访时间为6-65月,平均随访25月,恶性病例均无发生局部复发或远处转移。影像学随访病例中BosniakⅡ级为55例,ⅡF级26例, Ⅲ级为8例,Ⅳ级为1例,随访时间为6-64月,其中1例Ⅱ级（1.8%）进展至ⅡF级,其余病例均未进展。结论 Ⅱ、ⅡF级囊肿恶性率较低、进展缓慢建议定期随访,而Ⅲ、Ⅳ级恶性率较高应积极手术处理。但由于囊性肾癌组织学分级往往较低,其术后复发、进展及远处转移率较低,保肾手术是首选的治疗方案。     

输尿管软镜下钬激光内切开治疗肾盂旁囊肿的临床分析

目的探讨输尿管软镜下钬激光内切开治疗肾盂旁囊肿的安全性及临床疗效。 方法回顾性分析我院自2017年9月至2020年7月应用输尿管软镜钬激光内切开引流治疗的32例肾盂旁囊肿患者的临床资料。男21例,女11例,年龄35~68岁。囊肿大小3.5 cm×3.0 cm~7.0 cm×5.0 cm,平均（5.0±0.8）cm。均为单侧肾囊肿（BosniakⅠ型29例,BosniakⅡ型3例）。其中单发囊肿24例,多发囊肿5例,多囊肾1例,合并同侧结石2例。有8例合并不同程度肾积水。分析术前、术后囊肿变化情况、手术时间、术后住院天数、并发症等情况。 结果本组患者手术均顺利完成,无中转腹腔镜或开放手术。手术时间为22~68 min,平均（43±12） min,术后住院3~6 d（平均3.8±0.7）d,术后定期随访3~6个月。22例囊肿术后消失,9例囊肿术后缩小,1例多囊肾术后囊肿未见明显变化。8例肾积水患者积水均消失。手术相关并发症为18.75%,5例为ClavienⅠ级,1例为ClavienⅡ级。 结论输尿管软镜下钬激光内切开治疗肾盂旁囊肿具有创伤小、恢复快等优点,是安全、有效治疗方式,但远期疗效有待进一步随访观察。     

Laparoscopic management of renal cystic disease

Laparoscopic management of renal cystic disease is a highly effective, safe, and minimally invasive alternative to open surgery and antegrade or retrograde endoscopic procedures. Simple renal cysts can be accessed either transperitoneally or retroperitoneally. Almost all studies of the laparoscopic approach have demonstrated great satisfaction in terms of efficacy, minimal complications, operative time, minimal blood loss, hospital stay, recuperation, and cosmesis over other methods of treating renal cysts. Laparoscopic unroofing of peripelvic cysts is more challenging owing to their proximity to hilar vessels and the collecting system. Such surgery should be considered an advanced laparoscopic procedure. Access may be achieved either transperitoneally or retroperitoneoscopically. The basic principle of adequate exposure is essential for effective treatment. If the cyst is not completely excised, the surgeon must fulgurate the edge and tack perirenal fat in the residual cyst cavity to prevent recurrence and facilitate drainage. Laparoscopic evaluation of complex cysts seems to be sound. The results are promising, and follow-up does not show any increase in peritoneal seeding, tract recurrence, or distant metastases in the small number of neoplasms diagnosed at laparoscopy. Nevertheless, more studies are required with long-term follow-up. Bosniak type IV renal cysts or malignancy in renal cysts can be managed by laparoscopic radical nephrectomy with either access. Laparoscopic cyst marsupialization in patients with ADPKD is the latest emerging indication for laparoscopy in renal cystic disease. This procedure not only effectively reduces pain in some patients but also improves hypertension and stabilizes renal function, delaying renal replacement therapy. Long-term follow-up and further evaluation are needed.     

"Indeterminate" cystic lesion of the kidney partially lined by small cells with clear cytoplasm--malignant or benign?

Complex renal cysts, which present radiographically as "indeterminate for malignancy" (Bosniak category III), can prove challenging both pathologically and clinically. We report a case of a renal cyst that, by standard radiographic and histologic criteria, should have been diagnosed as a malignant cystic renal cell carcinoma. However, the cytogenetic profile appeared more closely consistent with cystic renal adenoma or low-grade papillary renal cell carcinoma--tumors with limited metastatic potential. We postulate that other, similarly complex, renal cysts might also be more precisely defined by meticulous histopathologic examination, supported by cytogenetic study.     

Progression,interobserver agreement,and malignancy rate in complex renal cysts (≥Bosniak category IIF)

ObjectiveThe objective of this study was to assess interobserver agreement, clinicopathologic correlation, and radiologic follow-up progression of complex cystic renal masses.Patients and methodsThe medical records of 143 patients with 154 complex cystic renal masses were retrieved. Primary outcomes were interobserver agreement between the radiologists, and malignancy rates following surgical extirpation with or without follow-up in Bosniak IIF, III, and IV categories. Secondary outcomes were correlation between histology and degree of enhancement on contrast-enhanced computed tomography scans and survival analysis of patients with or without surgical intervention using the Kaplan-Meier analysis.ResultsThe overall malignancy rate in patients who had surgery was 74.5% (29/39). Of 27 confirmed renal cell carcinoma on final histology, 9 were papillary renal cell carcinoma (incidence 33.3%). Assessment of interobserver agreement yielded a weighted kappa statistic value of 0.69 (95% confidence interval 0.56–0.82, P<0.0001). Radiologic progression rate of Bosniak IIF cysts over median follow-up of 18.5 months was 13% (10/78). There was no statistically significant difference between progression rate and regression rate of IIF cysts (13.8% vs. 11.5%) over the period of 24 months of follow-up. Most of the progression in complex cystic renal masses was seen in the first 2 years of follow-up. The malignancy rate on radiologic progression was 87.5% (8/9) and 75% (6/8) in Bosniak IIF and III cystic masses, respectively. The malignancy rate in Bosniak III cyst was 50% (4/8) without a period of initial observation or follow-up.ConclusionsA good degree of agreement exists between radiologists in classifying complex renal masses. Malignancy rate is considerably high in Bosniak IIF when they exhibit radiologic progression on systematic follow-up.     

Diagnostischer Algorithmus bei zystischen Nierenläsionen

Cystic renal lesions can be classified as either simple or complicated cysts, which might occur as solitary as well as multifocal lesions. The Bosniak classification (I-IV), which characterizes renal cysts on the basis of ultrasound or computer tomographic criteria, is very useful for further decision-making about the therapeutic approach. The method of choice for diagnosis of renal cysts is ultrasound. Besides the conventional B-mode ultrasound, contrast enhanced ultrasound with SonoVue® provides a promising new technique for distinguishing cysts according to the Bosniak classification. This review describes cystic renal lesions with emphasis on the etiology and significance of these pathologies in a methodological comparison of conventional B-mode, contrast enhanced ultrasound and computer tomography.     

BosniakⅠ型肾囊性病变发生癌变的诊治经验(附5例报告)

目的:总结BosniakⅠ型肾囊性占位病变发生癌变的诊治经验。方法:回顾性分析5例BosniakⅠ型肾囊性恶性病变的B超、CT、病理特征、治疗方法和随访结果:男3例,女2例;年龄42～72岁,平均54岁。患侧腰酸1例,体检发现4例。囊腔直径5.5～8.0cm。术前B超及CT均诊断为肾囊肿。结果:5例均行腹腔镜下肾囊肿去顶术,术后病理检查诊断为透明细胞癌,再次行根治性肾切除术。5例随访6～33个月,4例无瘤存活,1例因心血管疾病死亡。结论:重视BosniakⅠ型肾囊性病变的影像学和病理学特征,术中行冷冻切片病理检查是提高BosniakⅠ型囊性肾癌诊治水平的关键。     

An evaluation of Bosniak's radiological classification of cystic renal masses

OBJECTIVE: To determine the clinical usefulness of Bosniak's classification of cystic renal masses, the differentiation of which remains difficult despite significant advances in diagnostic imaging. PATIENTS AND METHODS: The computed tomography (CT) findings of all histopathologically examined cystic renal masses diagnosed at our institution were analysed retrospectively; 35 patients with cystic renal masses were treated between 1986 and 1998. Tissues surgically removed were examined pathologically and the final diagnosis compared with the preoperative CT category of Bosniak's classification. RESULTS: The histopathological examined showed cystic renal cell carcinoma in 21 patients, a benign renal cyst in 12, haemangiosarcoma in one and transitional cell carcinoma in one. Most of the 35 masses (26, 74%) were found incidentally during evaluation for an unrelated disease or a routine health check. All 11 masses of Bosniak category I were benign and one category II mass was malignant. All 10 masses of category III and 12 of category IV were malignant. CONCLUSIONS: Bosniak's classification is useful for differentiating category I, III and IV cystic renal masses. There were too few samples to allow meaningful conclusions to be drawn for category II renal masses. It is critical to differentiate between complicated cysts of category II and III because of the major implications for prognosis and clinical management.     

Pathological characteristics and radiographic correlates of complex renal cysts

ObjectivesTo characterize pathological and cancer-specific outcomes of surgically resected cystic renal tumors and to identify clinical or radiographic features associated with these outcomes.Methods and materialsAll patients at our institution who underwent radical or partial nephrectomy for complex renal cystic masses between 2004 and 2011 with available computed tomographic imaging were included. The Bosniak score was determined, as were 10 specific radiographic characteristics of renal cysts in patients with preoperative imaging available for review. These characteristics were correlated with cystic mass histopathology. Recurrence-free survival after surgery was determined.ResultsOverall, 133 patients underwent renal surgery for complex cystic lesions, 89 (67%) of whom had malignant lesions. Malignancy risk increased with Bosniak score (P≤0.01) and presence of mural nodules (P = 0.01). Most (63%) malignancies demonstrated clear cell histology. The papillary renal cell carcinomas (25%) exhibited lower enhancement levels (P = 0.04) and were less often septated (P<0.01). Of the malignancies, 79% were low stage (pT1), and 73% were Fuhrman grade 1 or 2. Large cyst size was associated with advanced tumor stage (P = 0.05). Neither Bosniak score nor any other radiographic parameter was associated with Fuhrman grade. In 70 patients with a median follow-up of 43 months, only 1 (1.4%) developed disease recurrence.ConclusionsMost cystic renal malignancies are low-stage, low-grade lesions. Papillary renal cell carcinomas account for nearly a quarter of cystic renal malignancies and have unique radiographic characteristics. Disease recurrence after surgical resection is rare. These findings suggest an indolent behavior for cystic renal tumors, and these lesions may be amenable to active surveillance.     

输尿管软镜切开内引流治疗肾盂旁囊肿的初步经验

目的探讨输尿管软镜下钬激光切开内引流治疗肾盂旁囊肿的疗效和安全性。 方法分析2014年1月至2017年1月河南省立院行输尿管软镜下钬激光切开内引流治疗的16例肾盂旁囊肿患者临床资料。男10例,女6例,年龄40~71岁,平均54岁,术前影像学检查诊断为肾盂旁囊肿,均为单侧肾盂旁囊肿,囊肿挤压肾盂、肾盏,囊肿表面正常肾皮质较厚,均为Bosniak I类囊肿,囊肿直径3~7 cm,合并同侧或对侧单纯性肾囊肿2例,合并同侧肾结石1例。 结果16例患者手术均成功完成,无中转开放手术。手术时间29~60 min,平均40 min;术后住院5~7 d,平均6 d。术后定期随访3个月~2年,13例囊肿消失,2例囊肿直径较术前缩小1/2以上,1例术后复发再次行输尿管软镜下切开引流术治愈。 结论输尿管软镜钬激光切开引流术治疗经合理选择的肾盂旁囊肿创伤小,安全有效,是治疗此类囊肿的理想方法。     

Management of adult choledochal cysts.

A review of the English literature reveals a total of 1,337 patients with choledochal cysts. Improved diagnostic techniques to visualize the biliary system are demonstrating an increasing number of unsuspected choledochal cysts in adult patients. Either choledochal cysts remain clinically silent until adulthood or may develop in later life. Experience is reported with adult patients having type I, II, III, and IV choledochal cysts. Type I cysts are preferably managed by excision but cyst anatomy may necessitate choledochoenteric drainage. Type II cysts are treated by excision except for those located within the pancreatic portion of the common bile duct. These are best managed by transduodenal cystoduodenostomy. The type III cyst (choledochocele) should be excised carefully, identifying and preserving the common bile and pancreatic ducts. Type IV cysts include a combination of any one of the first three types of cyst plus the presence of intrahepatic cyst or cysts. Treatment of these cysts is dictated by the type and location of the extrahepatic cyst. Since choledochal cysts are being recognized with increased frequency in adults, surgeons need to be aware of the diagnostic and treatment modalities available for each type of biliary cyst.     

Simple and complex renal cysts in adults: Classification system for renal cystic masses

Ultrasound and slice imaging are currently the key modalities for diagnosing simple renal cysts. Benign simple renal cysts are defined by a set of strict criteria. Any cystic lesions that do not meet these criteria should be classified as “atypical” or “complex” and considered as suspicious. For over three decades, the Bosniak classification has been the central tool for diagnosing renal cystic masses larger than 1 cm. The Bosniak classification is based upon the results of a well-established pre- and post-contrast computed tomography (CT) protocol. Lesions that are difficult to classify or that remain indeterminate after CT can benefit from a multimodal diagnostic approach combining CT, non-contrast-enhanced and contrast-enhanced ultrasound, and magnetic resonance imaging.