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.     

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.     

Malignant B-cell lymphoma in renal cyst wall

Renal cysts are frequently found in adults older than 50 years of age. Bosniak type III and IV cysts are commonly associated with malignancy, but most Bosniak I and II lesions are benign, and the optimal management has not been clearly defined. Although computed tomography and ultrasound examinations have improved diagnostic accuracy, some masses will remain indeterminate and require more invasive evaluation. We report a patient with a Bosniak type II renal cyst associated with malignant B-cell lymphoma in the cyst wall diagnosed after laparoscopic renal exploration.     

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 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.     

经皮囊内入路电切去顶术治疗单纯性肾囊肿16例报告

目的:评估经皮囊内入路电切去顶术治疗单纯性肾囊肿的疗效,以探讨低侵袭性、彻底的肾囊肿治疗方式。方法:我院于2011年4月~2013年12月采用经皮肾穿刺囊肿去顶术治疗单纯性肾囊肿患者16例。患者平均年龄59(23~78)岁;囊肿位于左肾13例,右肾3例。囊肿直径平均8.2(5.2~12.8)cm。术中在超声定位下应用经皮肾穿刺技术配合双极电切镜切除游离于肾脏外侧的囊壁,术后留置引流管2d。结果:14例患者手术顺利完成,囊肿完全消失。意外发现1例肾细胞癌,二期行肾部分切除术;1例因出血中转开放手术。平均手术时间68(15~125)min。平均随访15(1~32)个月,未见复发。结论:单纯性肾囊肿可以用经皮肾穿刺去顶术安全解决。此技术优于腹腔镜肾囊肿去顶减压术,避免了多个trocar的安置及广泛的肾周剥离,降低了手术难度。     

Spontaneous rupture of infected renal cyst presenting sudden onset of right flank distension: a case report

A 21-year-old woman was referred to our hospital for sudden onset of right flank distension. Ultrasonography, abdominal CT scan and MRI revealed a giant cyst 20 x 11 x 10 cm on the right kidney. Percutaneous puncture of the lesion was performed and fluid was drained. The fluid was yellowish and puriform. Gradually, the drainage fluid creatinine concentration increased. Cystography revealed communication between the lesion and the pyelocalyceal system. The patient underwent drainage for 25 days, causing the cyst to almost fully collapse. No recurrence has been detected in the follow-up for about 1 year. This case is the 38th case of the rupture of a renal cyst reported in the Japanese literature. We reviewed 37 cases of rupture of renal cysts previously reported in Japan.     

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。     

Retroperitoneoscopic deroofing of a giant renal cyst in a solitary functioning hydronephrotic kidney with a 3-port technique

To explore the safety and feasibility of performing retroperitoneoscopic renal cystectomy in a case of massive giant renal cyst in a solitary hydronephrotic renal unit. We have described the retroperitoneal three-trocar technique. The role of laparoscopic renal cyst ablation in giant symptomatic renal cysts and non-polycystic kidney disease has been discussed. The patient was successfully managed by retroperitoneoscopic deroofing using a three-port technique. The operating room time was 90 minutes and her hospital stay lasted 54 hours. The fluid cytology and cyst histology were negative for tumor. Complete resolution of the cyst was noted on a follow-up ultrasound done after 2 months. Currently at 9-month follow up, the patient is ultrasonographically free of any cyst recurrence or hydronephrosis. The retroperitoneal approach is feasible for marsupializing giant symptomatic renal cysts and appears to be safe for solitary symptomatic renal units too. It shortens the overall operating time and avoids the complications and demerits of transperitoneal access.     

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。     

Laparoscopic treatment of nonparasitic hepatic cysts

Background We present our experience with laparoscopic deroofing of nonparasitic hepatic cysts. Methods Laparoscopic deroofing was performed due to a solitary hepatic cyst in 21 patients and polycystic liver in four patients. Laparoscopy was indicated when a cyst was larger than 5 cm (the general size of cysts was 6.9 cm) and caused complaints and was in a superficial position. In eight patients in whom the cyst was larger than 10 cm, omentoplasty was performed. Results Intraoperative complications were not detected. Two conversions were performed because of the deep position of the cyst. Postoperative bile leakage was detected in one case that was treated conservatively. The average hospital stay was 4.7 days. Relapse occurred in two patients (8%), but only one of them required a second operation. Conclusions We recommend laparoscopic deroofing for treatment of nonparasitic liver cysts. This operation causes only slight discomfort for the patients, the intra- and postoperative morbidity is low, and relapses are rare.     

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.     

Bosniak肾囊性病变分类的临床应用价值

目的 探讨Bosniak分类在肾囊性病变中的临床应用价值.方法 收集2002至2007年手术治疗497例肾囊性病变患者资料.男284例,女213例.平均年龄42岁.病变位于左侧212例,右侧265例,双侧20例.病变直径1.8～11.5 cm,平均5.4 cm.按照Bosniak分类,I类囊肿339例、Ⅱ类49例(其中Ⅱ F 23例)、Ⅲ类44例、Ⅳ类65例.行肾囊肿去顶减压术372例,肾部分切除术51例,根治性肾切除术74例.结果 病理报告为肾恶性肿瘤89例(透明细胞癌74例、乳头状癌12例、低分化癌3例),良性病变408例(单纯囊肿382例、囊肿伴出血6例、囊肿伴感染6例、多房囊性肾瘤5例、纤维囊壁组织9例).I类囊肿中恶性病变3例(O.9%)、Ⅱ类中5例[10.2%,其中非ⅡF为7.7%(2/26),ⅡF为13.O%(3/23)3、Ⅲ类中23例(52.3%)、Ⅳ类中58例(89.2%).组间比较差异有统计学意义(P0.05).403例获随访,随访时间1～5年.75例恶性病变患者中术后1～5年出现肿瘤局部复发和(或)转移9例;328例良性病变中,术后2～5年出现囊肿复发26例.结论 Bosniak分类I类和Ⅱ类肾囊肿一般并不需要积极的外科处理,但ⅡF类囊肿和直径进行性增大以及形态变化明显的囊肿需要引起重视;Ⅲ、Ⅳ类肾囊肿恶变率较高,具备明确手术治疗指征,建议积极处理.     

Laparoscopic treatment using an argon beam coagulator for nonparasitic liver cysts

BACKGROUND: Laparoscopic deroofing has been shown to produce good patient satisfaction and to have results similar to those of open surgical techniques. We evaluated the feasibility and efficacy of laparoscopic deroofing using an argon beam coagulator (ABC) in the patients with nonparasitic liver cysts. METHODS: Laparoscopic deroofing for the treatment of liver cysts was attempted on 14 patients. After the deroofing, the secreting epithelium within the residual cystic cavity wall was destroyed using the ABC. RESULTS: Laparoscopic deroofing was successful in all patients. No deaths or surgical morbidity occurred, and no postoperative complications were recorded. The median postoperative hospital stay was 7 days. The median follow-up was 56 months for all patients, and all patients have remained completely asymptomatic for 6 months after the surgery, with no recurrence of the cysts. CONCLUSIONS: Our results indicate that laparoscopic deroofing using the ABC method in patients with nonparasitic liver cysts was effective in preventing cyst recurrence.     

Renal Cysts in Living Donor Kidney Transplantation: Long-Term Follow-up in 25 Patients

Introduction

The acceptance of a living donor kidney bearing cysts might implicate complications after the transplantation due to the natural history of renal cysts. We have presented our experience with transplantation of living donor kidneys containing cysts but not polycystic disease.

Patients and methods

We retrospectively reviewed donor and recipient records of all living kidney transplants performed between January 1997 and April 2008. We analyzed serum creatinine and urea levels, as well as ultrasound scans concerning cyst size and morphology at hospital discharge as well as at 12 and 24 months after transplantation.

Results

Among 268 living kidney transplantations, we noted 25 donors with renal cysts. In the computed tomography scan reports, 19 kidneys were described to show a single and six, multiple cysts. The size of 10 single cysts was <5 mm; the other nine were a mean of 17.33 mm. Two of the multiple cyst kidneys had lesions <5 mm; in four kidneys, the mean cyst size was 27.25 mm. The renal function of the recipients was normal or almost normal at discharge with a tendency to lower levels at 12 and 24 months after transplantation. Ultrasound revealed changes in cyst diameter among 6/23 kidneys; the mean diameter increased after 12 months, namely, 8.25 mm to 11.5 mm after 24 months. The subgroup of patients with enlarged cysts showed creatinine and urea levels slightly higher than in the entire group. No aspects of malignancy were found, according to the Bosniak and Israel classification system. One suspicious cyst was tomographically confirmed to be hemorrhagic without any need for treatment. None of the living donors had any problems related to the donor nephrectomy or a need for dialysis due to renal insufficiency in the long term. In addition, the living donors who had even beforehand cystic lesions in their contralateral nonremoved kidney at the time of transplantation did not show complications upon follow-up.

Conclusions

In our study, 25 living donor kidneys carried cysts. Neither cyst-related complications nor dysfunction of the transplanted organs occurred. An unroofing or excision of the cyst was generally not necessary. Regular ultrasound scans and optional computed tomography scans are recommended for follow-up. Based on this experience, we concluded that kidneys presenting cystic diseases should be considered to be suitable for transplantation without a hazard to the recipients, thus extending the pool of organs.     

The management of simple hepatic cysts: sclerotherapy or laparoscopic fenestration.

BACKGROUND: Prior to the era of laparoscopic surgery, open surgical deroofing was considered to be the most appropriate therapy for uncomplicated simple hepatic cysts. Recently, there have been a number of reports of successful laparoscopic fenestration of simple hepatic cysts. Simple aspiration of these cysts is associated with a high recurrence rate. Cyst sclerosis with alcohol and, more recently, minocycline hydrochloride have been found to be effective in their management. So far there have been no trials comparing laparoscopic deroofing with sclerotherapy. A lack of consensus in their management results in considerable confusion and difficulty in deciding the optimum form of therapy. METHODS: A systematic review of articles on the subject appearing in journals in the English language was conducted using the Medline database and by cross-referencing. RESULTS AND CONCLUSIONS: Both laparoscopic deroofing and cyst sclerosis have been found to be effective in partial or complete obliteration of the cyst and in the relief of symptoms produced by the cyst. It is essential to rule out cystadenoma, malignancy, biliary communication and infection prior to treating these cysts. Alcohol/minocycline based sclerotherapy has the advantage of being associated with a lower incidence of complications. Surgery is indicated if it is difficult to rule out the above mentioned conditions, in the presence of biliary communication, in those cysts where sclerosis has been ineffective and in cases of recurrence. The choice between open and laparoscopic surgery depends on the location of the cysts within the liver parenchyma.     

Experience with different methods of treatment of nonparasitic liver cysts

BACKGROUND AND AIMS: In a search for the optimal management of nonparasitic liver cysts, a study was made of the effectiveness of different methods. PATIENTS AND METHODS: Between 1 January 1982 and 15 December 2001 we treated 132 patients with nonparasitic liver cysts. In 72 patients 31 cysts were treated with enucleation, 60 with deroofing, and 24 with stitching by laparotomy; two liver resections were also performed. In a further 34 patients 36 cysts were treated with deroofing by minimally invasive surgery. In an additional 26 patients 32 cysts were treated with various interventional radiological methods. RESULTS: There was no mortality. The morbidity rate after laparotomy was significant (22.2%). The rate of recurrence after enucleation and deroofing was 6.5% and 13.8%, respectively, but there were no recurrences after stitching and liver resection. The recurrence rate following laparoscopic deroofing was 19.4%, and that following interventional radiological procedures was 50%. CONCLUSIONS: Treatment is required only if cysts are highly symptomatic or if growth is detected. Interventional radiological methods do not prove more favorable than surgery. Laparoscopic fenestration is preferred because of its low morbidity and the short period of hospitalization. Traditional surgical methods should be reserved merely for cases in which laparoscopic deroofing is not feasible.     

Laparoscopic deroofing for symptomatic liver systs: Report of a case

We present herein the case of a 73-year-old woman with symptomatic liver cysts and cholelithiasis for whom successful deroofing of the liver cysts and cholecystectomy were performed via laparoscopy. Histopathological diagnosis of the resected cyst wall and direct observation of the inner surface of the remaining cyst wall confirmed that they were benign biliary cysts. The laparoscopic deroofing of liver cysts is therefore not only an effective means of treatment, but it also facilitates the establishment of an exact differential diagnosis.     

后腹腔镜手术治疗16例肾盂旁囊肿

目的探讨后腹腔镜手术治疗肾盂旁囊肿的疗效。方法2005年8月～2008年12月16例肾盂旁囊肿行后腹腔镜囊肿去顶减压术。采用全身麻醉,经后腹腔途径建立后腹腔操作空间,沿输尿管寻找到肾盂旁囊肿,距正常肾实质3～5mm处行囊肿去顶。结果15例手术成功,手术时间（75±20）min,术中出血量（28±8）ml,未出现肾蒂及肾盂损伤等并发症;1例因囊肿暴露困难中转开放手术。16例术后随访6～20个月（平均13个月）,均未见复发。结论后腹腔镜治疗肾盂旁囊肿微创、安全、有效。