Laparoscopic management of renal cystic disease

Renal cystic disease, ranging from simple cysts to autosomal dominant polycystic kidney disease (ADPKD), can lead to significant complications such as pain, hypertension, infection, upper urinary tract obstruction, and even renal failure. For patients with preserved renal function, laparoscopic ablation of renal cysts is a recent, though safe and effective alternative to open surgery in patients who have failed conservative measures. Likewise, for symptomatic patients with renal failure, laparoscopic nephrectomy offers a less invasive option to open nephrectomy. Both laparoscopic cyst decortication and laparoscopic nephrectomy offer patients the benefits of minimal intraoperative blood loss, minimal postoperative pain, brief hospital stay, and rapid convalescence while offering a short-term outcome equivalent to open surgery. Further study and follow-up are indicated to assess the long-term effect of these procedures on the outcome of ADPKD with regard to durability of pain relief, preservation of renal function, and impact on renal hypertension.     

Renal cystic disease. Laparoscopic management

Laparoscopy offers a safe and efficacious means of ablating symptomatic simple renal cysts while conferring the usual benefits of shorter hospital stay, quicker convalescence, and reduced postoperative pain, although no direct comparison with open surgery has been performed. For indeterminate, complex renal cysts, laparoscopic exploration may spare the patient a morbid open operation to assess a cystic lesion of indeterminant risk. Although laparoscopic removal of kidneys with ADPKD remains a technically challenging exercise, centers of laparoscopic expertise have demonstrated the safety and feasibility of the procedure, thereby expanding the benefits of laparoscopic surgery to patients traditionally relegated to open surgical management.     

Laparoscopic management of cystic disease of the liver

Background: Laparoscopic management of cystic disease of the liver, including severe polycystic disease, is evolving. Methods: Wide unroofing, or ``fenestration,'' as is required for a successful result in open cases, leads to complete resolution of the cysts. This can even occur in chronic cysts, with wide-enough unroofing, given time. Results: In polycystic disease, adequate fenestration of superficial cysts allows deeper cysts to prolapse and be similarly fenestrated, thus reducing pressure effects on the liver and restoring normal function. Conclusion: However, because of the distortion of anatomy by this disease, it is important that an experienced liver surgeon perform such a complex procedure, as operative complications could be severe.     

Acquired renal cystic disease

In 1977, Dunnill et al. described a new disorder, bilateral multiple renal cystic disease. It occurred among hemodialysis patients whose original illness had not been cyst-related. Acquired cystic disease of the kidney (ACDK) is commonly observed in patients undergoing hemodialysis. The incidence of ACDK is 40-50% in reports of autopsy and surgical specimens, rising to more than 90% after 5-10 years of dialysis. The volume of the kidneys decreases in the first 3 years of dialysis and then increases as the rate of cyst formation increases. In male patients undergoing long-term hemodialysis the incidence of ACDK is markedly high. ACDK is also found in patients before hemodialysis. The primary concern in patients with ACDK is the increased incidence (5-19%) of renal cell carcinoma (RCC). The incidence is about twelve to eighteen times higher than that in the general population and the cancers may be asymptomatic. Therefore, screening is essential if carcinomas are to be detected early. Regular screening by ultrasonic examination or CT scan is needed. A patient requires nephrectomy when the kidney cancer exists or is suspected by dynamic CT scan. Nephrectomy is performed only on the side with renal mass. It has been argued that RCC associated with ACDK are innocuous and do not predispose the patient to an increased risk of death from RCC. RCC arising from ACDK is considered to be a tumor of low malignant potential, compared with classic RCC. However, RCC has been reported to metastasize in 16% of the patients on dialysis and to be the cause of death in 2% of the kidney transplant recipients. The etiology of ACDK is unclear and its incidence increases with the duration of dialysis. ACDK patients have a propensity to develop adenocarcinoma. The increased incidence of RCC in ACDK patients warrants careful radiologic monitoring of end-stage kidneys in selected patients.     

Unilateral renal cystic disease

Unilateral renal cystic disease (URCD) is an uncommon, nonfamilial, and nonprogressive disorder of the kidney characterized by replacement of all or part of one kidney by multiple cysts. Initially thought to be a form of autosomal dominant polycystic kidney disease (ADPKD), its benign clinical course, lack of family history of cystic renal disease, and absence of cysts in other organs distinguish URCD from ADPKD. Review of English language published reports revealed only 6 documented cases of URCD in adults. We describe 3 cases (2 new) of adult URCD and review the diagnosis and management of this rare entity.     

Unilateral renal cystic disease

Unilateral and localized cystic disease of the kidney, is characterized by the substitution of either all or a portion of one of the kidneys, by no encapsulated, multiple simple cysts. We present a case--to our knowledge the first in the Spanish bibliography-, of this rare benign condition that needs to be recognized to be differentiated from more transcendent ones. Contrary to autosomal dominant polycystic kidney disease, it is unilateral, it is not familiar, and it is neither progressive nor associated with renal insufficiency or with cysts in other abdominal organs. Lack of encapsulation allows, in general, to distinguish it from multilocular cystic nephroma and cystic renal carcinoma.     

Laparoscopic management of benign cystic lesions of the liver

We present our experience in the laparoscopic management of benign liver cysts. The aim of the study was to analyze the technical feasibility of such management and to evaluate safety and outcome on follow-up. Between September 1990 and October 1997, 31 patients underwent laparoscopic liver surgery for benign cystic lesions. Indications were: solitary giant liver cysts (n = 16); polycystic liver disease (PLD; n = 9); and hydatid cysts (n = 6). All giant solitary liver cysts were considered for laparoscopy. Only patients with PLD and large dominant cysts located in anterior liver segments, and patients with large hydatid cysts, regardless of segment or small partially calcified cysts in a safe laparoscopic segment, were included. Patients with cholangitis, cirrhosis, and significant cardiac disease were excluded. Data were collected prospectively. The procedures were completed laparoscopically in 29 patients. The median size of the solitary liver cysts was 14 cm (range, 7–22 cm). Conversion to laparotomy occurred in 2 patients (6.4%), to control bleeding. The median operative time was 141 min (range, 94–165 min) for patients with PLD and 179 min (range, 88–211 min) for patients with hydatid cysts. All solitary liver cysts were fenestrated in less than 1 h. There were no deaths. Complications occurred in 6 patients (19%). Two hemorrhagic and two infectious complications were noted after management of hydatid cysts. Three patients were transfused. The median length of hospital stay was 1.3 days (range, 1–3 days), 3 days (range, 2–7 days), and 5 days (range, 2–17 days) for solitary cyst, PLD, and hydatid cysts, respectively. Median follow-up was 30 months (range, 3–78 months). There was no recurrence of solitary liver cyst or hydatid cysts. One patient with PLD presented with symptomatic recurrent cysts at 6 months, requiring laparotomy. We conclude that laparoscopic liver surgery can be accomplished safely in patients with giant solitary cysts, regardless of location. The laparoscopic management of polycystic liver disease should be reserved for patients with a limited number of large, anteriorly located cysts. Hydatid disease is best treated through an open approach. Received for publication on Aug. 21, 1999; accepted on Sept. 2, 1999     

Laparoscopic management of symptomatic simple renal cysts

Objective: To evaluate the efficacy of retroperitoneoscopy for the treatment of symptomatic renal cyst disease. Patients and methods: We evaluated the efficacy and morbidity of aspiration versus open and laparoscopic surgical techniques in a paired institution over a 20-year period. Prospectively recorded parameters for the 11 cases dealt with by primary retroperitoneoscopic techniques were compared with historical controls dealt with by open surgery. Results: Small volume cysts were satisfactorily dealt with by aspiration alone. All patients undergoing laparoscopic cyst decortication for the larger volume cysts had a satisfactory outcome with improvement in their symptoms and objective cure on follow up imaging studies. Conclusion: Laparoscopic management for all cysts is a safe, effective and minimally invasive alternative to open surgery for symptomatic renal cysts. Simple drainage under radiological guidance is also highly effective and should probably be first line treatment for cysts up to 6 cms in diameter whereas primary laparoscopic treatment should be suggested for larger cysts. This revised version was published online in August 2006 with corrections to the Cover Date.     

Laparoscopic management of retrovesical cystic disease: Washington University experience and review of the literature.

BACKGROUND AND PURPOSE: Recently, the laparoscopic approach to the management of seminal vesicle cysts has been described. This report outlines the Washington University experience and reviews the present literature to evaluate the results of the laparoscopic approach to the excision of retrovesical cysts of seminal vesicle and Müllerian origin. PATIENTS AND METHODS: The hospital and office records of three patients undergoing laparoscopic excision of seminal vesicle and Müllerian duct cyst disease between April 1993 and March 1999 were reviewed for the operative time, the estimated blood loss, total hospital stay, total analgesia required postoperatively, the time to resumption of oral intake, and the postoperative recovery. A literature search revealed two additional reports of laparoscopic management of cystic disease of the seminal vesicle, comprising only one and two patients. An additional review of the literature was performed to compare the laparoscopic procedure with the transvesical, transurethral, open transvesical, and open retrovesical approach for the management of the disease. RESULTS: For the three patients at Washington University, the operative time averaged 4 hours (range 1.8-6.1 hours), and the mean estimated blood loss was 150 mL (range 50-200 nL). The patients required a mean of 43 mg of morphine sulfate for postoperative pain control, had a mean hospital stay of 2.6 days, and resumed oral intake 5.8 hours postoperatively. In combination with the three other cases reported in the literature, the average operative time for laparoscopic retrovesical cyst excision was 2.9 hours, and the average hospital stay was 2.2 days. With an average follow-up of 17 months, all six patients had excellent resolution of their preoperative symptoms. There have been no major or minor complications or any need for further operative therapy. CONCLUSION: Laparoscopic excision of retrovesical cystic disease is an effective surgical procedure, associated with minimal postoperative morbidity, short hospitalization, and a rapid recovery for the patient.     

Laparoscopic renal surgery for benign disease

Fifteen years after the first report, laparoscopic nephrectomy has demonstrated proven efficacy and safety comparable with an open approach, with a significant advantage of a faster recovery. Wide dissemination of these surgical techniques and continued improvement in instrumentation has made laparoscopy the preferred approach for treating benign pathologic conditions of the kidney. In this review, the expanding indications of laparoscopic simple nephrectomy and the outcomes of the larger clinical series are examined. We discuss the technical aspects of both transperitoneal and retroperitoneal approaches. Finally, laparoscopic cyst decortication and some of the novel applications of laparoscopic renal surgery are highlighted.     

腹腔镜与开放保留肾单位手术治疗囊性肾癌的比较

【摘要】目的 评价腹腔镜保留肾单位手术(laparoscopice nephron-sparing surgery,LNSS)与开放保留肾单位手术(open nephron-sparing surgery,ONSS)治疗囊性肾癌的优劣。方法 回顾性分析14例分别行 LNSS 患者(n=6)与行 ONSS 患者(n=8)的临床资料,比较两组患者术中出血量、手术时间、热缺血时间、术后疼痛评分、术后引流管天数、住院天数及术后随访资料并行统计学分析。结果 LNSS 组术中出血量、术后疼痛评分明显小于 ONSS 组,LNSS 组热缺血时间及手术时间长于 ONSS 组,差异有统计学意义(P<0.05),引流管留置时间及住院天数两者差异无统计学差异。结论 LNSS与ONSS 两种术式在囊性肾癌的治疗中各有优势,LNSS创伤更小,术后恢复更快,但手术要求高。     

Twenty-year follow-up of acquired renal cystic disease

AIMS: Since 1979 the diseased kidneys of 96 patients on replacement therapy with chronic renal failure due to chronic glomerulonephritis have been followed to investigate the development of acquired cysts and tumors. This is a report of the 20-year follow-up. MATERIALS AND METHODS: Ninety-six patients were followed using periodic CT scan and were divided into hemodialysis, renal transplantation, bilateral nephrectomy and deceased groups during the follow-up. In the hemodialysis group, 36 patients (19 males, 17 females) were followed for 20 years. RESULTS: Kidney volumes which were 57.8 (1.51) (geometric mean (geometric SD)) ml at start of the follow-up had become 185.3 (2.03) ml 20 years later in males, and in females, 57.3 (1.64) ml had become 99.7 (2.36) ml. The increased rate was 3.2 (2.06) fold in males and 1.7 (2.57) fold in females. This enlargement of the kidneys was due to acquired cysts. Kidney volumes at the 20-year follow-up had increased more significantly than those at the 15-year follow-up in males; however, kidney volumes at the 20-year follow-up had not changed in females, if compared with data at the 15-year follow-up. Kidney volumes in males at 20-year follow-up were significantly larger than those in females (p = 0.0232). Males with more than 3.2-fold in kidney volume increase at the 20-year follow-up were under the age of 40 at entry into this study (p = 0.0055), although the correlation between the degree of kidney volume increase and age was not significant (p = 0.0910). Kidney volumes in the transplantation group remained small. There was no new renal cell carcinoma development after 15-year follow-up except for the local recurrence of a previous operated case. Although 7 of 44 patients died during the past 20 years due to malignancy, no patient died of renal cell carcinoma because of early detection and treatment. One patient died of retroperitoneal bleeding, which is a complication of acquired renal cystic disease. CONCLUSION: Male preponderance of acquired cysts was maintained at the 20-year follow-up. There was a tendency for the rate of increase in acquired renal cystic disease to be larger in young males. No one died of renal cell carcinoma, although the incidence of renal cell carcinoma was high.     

Laparoscopic management of benign liver disease

Minimally invasive techniques may be used for treating a variety of benign hepatic lesions in selected patients. The size of the lesions is less important than the anatomic location in anterolateral regions. Laparoscopic unroofing of solitary liver cysts is the surgery of choice for this indication. The laparoscopic management of patients with PLD should be reserved for patients with a few, large, anteriorly located, symptomatic cysts. Active hydatid cysts present technical difficulties because of their complex biliovascular connections and the inherent nature of the parasite. The authors' results do not support the widespread use of laparoscopy in these cases. Uncomplicated benign liver tumors located in the left lobe or in the anterior segments of the right lobe can be resected safely using a four-hand technique. Open surgery is the treatment of choice when primary tumors are malignant, located posteriorly, or in proximity to major hepatic vasculature. Laparoscopic resection of liver metastases with a safety margin of 1 cm, when the total number is less than four, is not unreasonable and can be offered to patients without evidence of extrahepatic disease.