Laparoscopic nephrectomy for polycystic kidney: comparison of the transperitoneal and retroperitoneal approaches

Laparoscopic Nephrectomy Via the Retroperitoneal Approach for Autosomal Dominant Polycystic Kidney Disease After Renal Transplant: A Case Report

We report a case of laparoscopic nephrectomy via the retroperitoneal approach for autosomal dominant polycystic kidney disease after renal transplant. A 54-year-old male patient with end-stage renal failure because of autosomal dominant polycystic kidney disease underwent a living donor renal transplant and right nephrectomy via open surgery through a median abdominal incision 5 years previously. However, the left kidney gradually became enlarged. We performed laparoscopic left nephrectomy via the retroperitoneal approach. After dissecting the renal vessels, we performed cyst puncture and aspiration to decrease the kidney volume. The patient's symptoms improved after operation. Laparoscopic nephrectomy for enlarged kidneys with multiple cysts can be safely performed, and the retroperitoneal approach can be preferred if the patient has a history of abdominal surgery or an enlarged polycystic kidney.

Native nephrectomy and arterial embolization of native kidney in autosomal dominant polycystic kidney disease patients: indications, timing and postoperative outcomes

INTRODUCTION

Autosomal dominant polycystic kidney disease (ADPKD) is one of the most common causes of a need of renal replacement therapy. The need (elective vs. systematic) and timing of native kidney nephrectomy (before, after or during kidney transplantation) is a matter of debate and alternatives to surgery, mainly transcatheter arterial embolization have been explored. We performed a systematic review to report all available evidence on postintervention outcomes of native nephrectomy and arterial embolization in ADPKD patients.

EVIDENCE ACQUISITION

A search on Medline, Embase, and Cochrane databases was performed to identify all studies reporting outcomes of native nephrectomy or arterial embolization in APKDs.

EVIDENCE SYNTHESIS

Concerning native nephrectomy, a total of 3626 patients in 37 studies were included with 735, 210 and 2681 patients who underwent native nephrectomy respectively before, after or during kidney transplantation. Major complications were 12.2% in unilateral nephrectomy before transplantation, 25.0% in bilateral nephrectomy before transplantation, 17.7% in unilateral nephrectomy during transplantation, 20.8% in bilateral nephrectomy during transplantation and 23.8% in unilateral and bilateral nephrectomy after transplantation. A total of 230 patients in 7 series of arterial embolization were included. All arterial embolization were performed before transplantation. Mean volume reduction ranged from 36.3% at 3 months to 49% at 6 months. The major postintervention complication rate was 1%.

CONCLUSIONS

Unilateral native nephrectomy before kidney transplantation was associated with the lowest major postoperative complication rate and appears to be the preferred strategy. Arterial embolization reduces kidney volume by 49% at 6 months. Arterial embolization could be considered when the reduction in size of the native kidney is not urgent.

A comparison of surgical practice and operative outcomes between retroperitoneal and transperitoneal laparoscopic nephrectomies – 6 years of data from the BAUS Nephrectomy database

Objectives:

While the choice of surgical approach for laparoscopic nephrectomy is broadly split between transperitoneal and retroperitoneal options, the evidence for the impact of this decision on perioperative outcomes is built on relatively small volume data, with often inconsistent findings and conclusions. We aimed to assess the impact of operative approach on perioperative outcomes for laparoscopic radical, partial and simple nephrectomy and nephroureterectomy through analysis of the British Association of Urological Surgeons (BAUS) Nephrectomy database.

Patients and methods:

All patients added to the BAUS Nephrectomy database with laparoscopic surgery between 2012 and 2017 inclusively were included and subdivided by operation and surgical approach. Preoperative patient and tumour characteristics, as well as intraoperative and post-operative short-term outcomes, were assessed.

Results:

Overall, 26,682 operations were documented over the review window (81.6% transperitoneal). Small increases in blood loss ( p = 0.001), transfusion rate ( p = 0.02) and operative length ( p = 0.01) were seen for transperitoneal radical nephrectomies and longer hospital stays seen for retroperitoneal procedures (radical nephrectomy p = 0.00l; partial nephrectomy p = 0.04). Retroperitoneal procedures were associated with increased rates of conversion for simple nephrectomy ( p = 0.02), nephroureterectomy ( p = 0.03) and most notably partial nephrectomy (10.5% versus 4.4%; p = 0.001). No further variation in intraoperative complications, post-operative complications, tumour margin positivity rates, unintended ITU admission, or likelihood of death was identified related to surgical approach.

Conclusion:

Observed variations in perioperative outcomes were generally modest in nature, and little ground is seen to support a change in operative technique for those committed to one approach. A caveat to this exists with open conversion for retroperitoneal partial nephrectomies and requires careful consideration of patient selection by the individual surgeon.

Level of evidence:

4

Perioperative morbidity of paediatric laparoscopic nephrectomy by transperitoneal and retroperitoneal approaches- any difference?

AIM

Minimal invasive approaches for paediatric nephrectomy include transperitoneal (TP) and retroperitoneal (RP); both having advantages and disadvantages. We aimed to ascertain if there was any difference in perioperative morbidities between these two approaches.

METHODS

We performed a retrospective review of laparoscopic TP and RP nephrectomies performed in our institution over 10 years from May 2009 till May 2019. Outcome measures included intraoperative complications, prolonged requirement of opioid analgesics (more than 24 h), hospital stay, incidence of wound infection and urinary tract infections. Data were analysed using Fisher's exact test and Mann Whitney test.

RESULTS

A total of 152 nephrectomies were performed in 139 patients; 81 were TP and 71 were RP. Age ranged from 8 months to 16 years. Median hospital stay was 2 days in both groups. There were no intraoperative complications. Outcome measures were sub-categorised as follows. Requirement of opioid analgesia for more than 24 h was documented in 2 patients in each group, leading to longer hospital stay of 3 days. A febrile urinary tract infection requiring antibiotics was detected in 4; 1 in TP and 3 in RP. Wound infection requiring antibiotics occurred in 1 patient (in RP group). No statistically significant difference was found between the two groups in any of the subcategories.

CONCLUSION

TP and RP nephrectomy have similar perioperative morbidity. The decision to utilise either approach should be dependent on the surgeon's skills and experience and appropriately tailored to individual patient needs.

Safety and Efficacy of Ultrasound-Guided Retrolaminar Block of Multiple Injections in Retroperitoneal Laparoscopic Nephrectomy: A Prospective Randomized Controlled Study

Purpose

Ultrasound-guided retrolaminar block (RLB) has the potential to provide postoperative analgesia in retroperitoneal laparoscopic surgery. This study was conducted to evaluate the effects of RLB when compared with local infiltration analgesia (LIA) in retroperitoneal laparoscopic nephrectomy.

Patients and Methods

One hundred and fifteen patients scheduled for laparoscopic nephrectomy were divided into two groups: the RLB group (n = 57) received an ultrasound-guided RLB, while the LIA group (n = 58) received LIA. At 2, 4, 6, 24, and 48 hours after operation, the maximal visual analog score (VAS), sufentanil and rescue analgesia consumption, and the utilization of patient-controlled intravenous analgesia (PCIA) were assessed. The incidence rates of postoperative nausea and vomiting (PONV); time of leaving bed (at the first instance); and the levels of plasma β-Endorphin (β-EP), Interleukin-1β (IL-1β), and prostaglandin E2 (PEG2) 30 min after extubation were noted.

Results

Patients in the RLB group had significantly lower VAS scores; lower sufentanil cumulative consumption; lower manual addition frequency of PCIA; lower proportion of using rescue analgesia within 48 hours after operation; lower incidence rate of PONV; shorter resuscitation times; earlier time of leaving the bed; and lower β-EP, IL-1 β, and PEG2 levels.

Conclusion

Ultrasound-guided RLB of multiple injections is both safe and controllable for postoperative analgesia after retroperitoneal laparoscopic nephrectomy. When compared with LIA, RLB has better and longer-lasting analgesic effect, lower incidence rates of PONV, and the potential to reduce the level of postoperative inflammatory factors.

Trial Registration

China Clinical Trials Registration Center (http://www.chictr.org.cn, No. ChiCTR1800017526, Date of registration: 2018-08-02).

Genitourinary Interventions in Autosomal Dominant Polycystic Kidney Disease: Clinical Recommendations for Urologic and Transplant Surgeons

Autosomal dominant polycystic kidney disease is the fourth most common single cause of end-stage renal disease worldwide with both renal and extrarenal manifestations, resulting in significant morbidity. Approaches to the management of this disease vary widely, with no broadly accepted practice guidelines. Herein, we reviewed the various surgical and interventional management options that are targeted toward treating the symptoms or addressing the resulting kidney failure. Novel treatment modalities such as celiac plexus blockade and renal denervation appear to be promising in pain relief; however, further studies are lacking. Renal cyst decortication seems to have a higher success rate in targeting cyst-related pain compared with aspiration only. In terms of requiring major surgical intervention, such as need and timing of native nephrectomy, there are several considerations when deciding on transplantation with or without a pretransplant native nephrectomy. Patients who are not candidates for native nephrectomy may consider transcatheter arterial embolization. Based on our review of the contemporary indications for genitourinary interventions in the management of autosomal dominant polycystic kidney disease, we propose an algorithm that depicts the decision-making process on assessing the indications and timing of native nephrectomy in patients with end-stage renal disease awaiting transplant.

Resection of adult polycystic kidney with retroperitoneal laparoscopic technique assisted by arterial embolization

Background

Traditional surgical methods have high complication rate and large injury in the resection of adult polycystic kidney. We investigated the effect of retroperitoneal laparoscopic resection of adult polycystic kidney assisted by arterial embolization.

Methods

The data of adult polycystic kidney patients who underwent laparoscopic surgery assisted by arterial embolization from November 2015 to November 2018 in our hospital were retrospectively analyzed, and the data of patients who underwent open surgery during the same period were collected. The basic data, surgical conditions, postoperative recover situation, and complications of the two groups were compared.

Results

There was no significant difference in the basic situation between the laparoscopic operation group and open operation (control) group. The bleeding volume, hospitalization time, and the length of incision in the laparoscopic operation group were significantly better than those in the open operation (control) group, but the operation time was significantly longer than that in the open operation group. There was no significant difference in drainage tube extraction time, bed rest time and blood transfusion rate between the two groups. There was no significant difference in the complication rate between the two groups.

Conclusions

Arterial interventional embolization-assisted retroperitoneal laparoscopy is an effective method for the resection of polycystic kidney.

Unilateral nephrectomy versus renal arterial embolization and technique survival in peritoneal dialysis patients with autosomal dominant polycystic kidney disease

BACKGROUND

Autosomal dominant polycystic kidney disease (ADPKD) is a common genetic disorder associated with progressive enlargement of the kidneys and liver. ADPKD patients may require renal volume reduction, especially before renal transplantation. The standard treatment is unilateral nephrectomy. However, surgery incurs a risk of blood transfusion and alloimmunization. Furthermore, when patients are treated with peritoneal dialysis (PD), surgery is associated with an increased risk of temporary or definitive switch to haemodialysis (HD). Unilateral renal arterial embolization can be used as an alternative approach to nephrectomy.

METHODS

We performed a multicentre retrospective study to compare the technique of survival of PD after transcatheter renal artery embolization with that of nephrectomy in an ADPKD population. We included ADPKD patients treated with PD submitted to renal volume reduction by either surgery or arterial embolization. Secondary objectives were to compare the frequency and duration of a temporary switch to HD in both groups and the impact of the procedure on PD adequacy parameters.

RESULTS

More than 700 patient files from 12 centres were screened. Only 37 patients met the inclusion criteria (i.e. treated with PD at the time of renal volume reduction) and were included in the study (21 embolized and 16 nephrectomized). Permanent switch to HD was observed in 6 embolized patients (28.6%) versus 11 nephrectomized patients (68.8%) (P = 0.0001). Renal artery embolization was associated with better technique survival: subdistribution hazard ratio (SHR) 0.29 [95% confidence interval (CI) 0.12-0.75; P = 0.01]. By multivariate analysis, renal volume reduction by embolization and male gender were associated with a decreased risk of switching to HD. After embolization, a decrease in PD adequacy parameters was observed but no embolized patients required temporary HD; the duration of hospitalization was significantly lower [5 days [interquartile range (IQR) 4.0-6.0] in the embolization group versus 8.5 days (IQR 6.0-11.0) in the surgery group.

CONCLUSIONS

Transcatheter renal artery embolization yields better technique survival of PD in ADPKD patients requiring renal volume reduction.

Robot assisted spinal surgery- A technical report on the use of DaVinci in orthopaedics

Background

Robot assisted procedures have evolved during the last years, today many surgical, units perform laparoscopic procedures with DaVinci on a regular Basis. The major advantages of Robot assisted procedures comprise technical factors and improved visualization. In Spinal surgery endoscopic stabilization of fractures has become a Standard for many.

Purpose

We have employed DaVinci as an access tool for a retroperitoneal lumbar approach followed by a DaVinci assisted corpectomy and cage implantation to treat a fracture of L3.

Study design

A single operation as proof of concept and demonstration of the method was performed.

Methods

The whole procedure was video recorded. Time factors and clinical outcome were documented.

Results

The procedure was performed safely with no complications. The operating time was longer than usual but within reasonable limits. The postoperatrive outcome did not differ from the usual procedure. The visualization of critical structure during preparation of the vertebral body was superior along with superior soft tissue management with DaVinci.

Conclusion

An endoscopic robotic instrument can be used for endoscopic access surgery. Despite major advantages in visualization and handling of the endoscopic instruments all bone and cartilage preparation must be performed in a traditional endoscpic way because no appropriate instruments are available at present. In order to perform full robotic assisted procedures, new instruments need to be developed.

The Harbin Medical University nephrectomy score: a quantitative system for evaluating the complexity of laparoscopic retroperitoneal simple nephrectomy

BACKGROUND

Laparoscopic retroperitoneal simple nephrectomy (LRSN) has been widely accepted as a mainstay option for benign non-functioning kidney. The complexity of the procedure, however, differs and remains a subject of controversy.

OBJECTIVE

To develop a standardised Harbin Medical University nephrectomy score (HMUNS) system for evaluating LRSN complexity.

SUBJECTS AND METHODS

A total of 6 variables with different factors comprising primary diseases, history of upper urinary tract surgery, body mass index (BMI), surgeon's learning curve, kidney volume, and Mayo Adhesive Probability (MAP) scores were included in the HMUN score. 95 consecutive patients who underwent LRSN at our institution were divided into low (2 to 6 points) and high (7 to 17 points) complexity groups with HMUNS and investigated the differences of operative time (OT), estimated blood loss (EBL), postoperative hospitalisation time (PHT), rate of intraoperative conversion to open surgery, and the Clavien-Dindo classifi cation (CDC) between both groups.

RESULTS

Longer mean operative times (193.2±69.3 min vs. 151.9±46.3 min, p <0.05), more median estimated blood loss (100.0mL vs. 50.0mL, p <0.05), and higher rates of conversion to open surgery (1.2% vs. 25%, p <0.05) were observed in the high-complexity group (n=12) than in the low-complexity group (n=83). However, there were no remarkable differences between the two groups related to the baseline characteristics, post-surgical hospitalisation times, and postoperative complications.

CONCLUSIONS

The HMUNS can effectively reflect LRSN complexity, thus providing a quantitative system for risk estimation and treatment decisions. Because of some limitations, further well-designed studies are necessary to confirm our fi ndings. Patient summary: The HMUNS, including primary diseases, history of upper urinary tract surgery, BMI, surgeon's learning curve, kidney volume, and MAP score, can provide an effective quantitative tool to evaluate the complexity of LRSN.

[Arterial embolization of polycystic kidneys as an alternative to ergonomic nephrectomy in renal pre-transplantation. Monocentric retrospective study]

PURPOSE

This study aims at providing a retrospective assessment of the decrease in renal volume after renal artery embolization (RAE) among a group of patients with autosomal dominant polycystic renal disease and for whom transplantation, for ergonomic reasons was temporarily advised against.

MATERIAL AND METHODS

Between November 2014 and March 2017, as part of pre-transplantory procedure 15 patients, including 11 men and 4 women benfited from renal embolization (RAE) in a context of preparation for transplant in Lille University Hospital. All of the patients were suffering from autosomal dominant polycystic renal disease (ADPKD) at a severe or terminal stage of renal disease.

RESULTS

The original mean total kidney volume (TKV) was 2550.6 cm³±1771 (1102 cm³; 7310 cm³), the average TKV at 3 months was 1684 cm³±1539 (648 cm³; 6930 cm³) with an average decrease of 33% in the volume (5.2%; 83.9%) (95% confidence interval [0.229-0.436]) (P<0.01) and 1632±1743 (599 cm³; 6758 cm³) at 6 months with an average decrease of 40.7% (7.6%; 64.1%) (IC95% 0.306-0.508) (P<0.01). Among the 15 patients, 13 had their contraindication removed and to date 7 have had successful transplants. One failure due to a very high initial volume (7310cm³) required a secondary nephrectomy. No post-embolization syndrome has been noticed, 2 minor complications occurred (13%) involving a difficult resumption of transit and there was one case of hematuria.

CONCLUSION

ERA procedures must have a place in the ergonomic transplant strategy of patients with ADPKD with a low complication rate and a high efficiency. Nephrectomy indications before transplantation must therefore be reconsidered due to a major postoperative risk. Our results are in line with larger scale studies. Nevertheless, these results need to be confirmed by a large-scale randomized prospective study.

LEVEL OF EVIDENCE

4.

Comparison of Laparoscopy and Open Radical Nephrectomy of Renal Cell Cancer

Objective

The aim of this study was to summarize the current evidence to evaluate the effects of laparoscopic radical nephrectomy (LRN) and open radical nephrectomy (ORN) in the treatment of renal cell carcinoma.

Methods

A comprehensive literature search was performed using PubMed, Embase and Google Scholar to identify all relevant studies. 8 published studies were included in this meta-analysis. We pooled the odds ratios (OR), standardised mean difference (SMD) and conducted heterogeneity, and quality assessment.

Results

The outcome of treatment effects included surgical blood loss, surgical time, postoperative complications, and post-operative length of hospital stay. Comparing open radical nephrectomy for kidney cancer patients, the pooled SMD of surgical time was 0.47, (95% confidential index CI = [0.09, 0.85]), the pooled SMD of operative blood loss was -68.98, (95% CI = [-99.63, -38.34]), the pooled SMD of post-operative length of hospital stay was -4.32, (95% CI = [-4.62, -4.03]), and the pooled OR of postoperative complications was 0.52, (95% CI = [0.30, 0.91]).

Conclusion

LRN was found to significantly decrease patients’ blood loss. In addition, LRN offers less post-operative length of hospital stay.

Minimally Invasive Surgery-Based Multidisciplinary Clinical Management of Reninoma: A Single-Center Study

Background

This article presents our experience in managing a rare kidney tumor – reninoma – by analyzing a relatively large series of cases from a single center.

Material/Methods

Nine cases of reninoma were reviewed. Clinical manifestations, imaging examinations, laboratory examinations, perioperative data, and pathological findings were summarized. A 58.8-month follow-up was performed to evaluate patient survival and recrudescence.

Results

The main clinical manifestations were hypertension, hypokalemia, headache, dizziness, nausea, vomiting, palpation, and sweating. Three patients had hypertensive end-organ damage, including brain hemorrhage, gestation termination, and grade III ocular fundus changes. All patients underwent retroperitoneal laparoscopic partial nephrectomy successfully. The mean warm ischemic time was 23.4 min. The median operation time was 95.1 min, with a median estimated blood loss of 60 ml. The median hospital stay was 6 days. No serious intraoperative or postoperative complications occurred. The histology and electron microscopy findings confirmed the diagnosis of reninoma in all cases. After 58.8 months of follow-up, symptoms involving hypertension were relieved in all patients, and no tumor recurrence or metastasis was detected.

Conclusions

Reninoma may have severe consequences despite being a benign tumor. Retroperitoneal laparoscopic partial nephrectomy is a feasible and effective method for the surgical removal of reninoma. Multidisciplinary cooperation plays an important role in improving the diagnosis and enabling the early surgical treatment of reninoma. Especially in cases of reninoma with moderate and high RENAL scores, an accurate diagnosis of reninoma based on multidisciplinary cooperation facilitates the selection of less invasive surgical approaches.