Laparoscopic Marsupialization of the Painful Polycystic Kidney

Developing a patient-centred tool for pain measurement and evaluation in autosomal dominant polycystic kidney disease

BACKGROUND

Pain affects 60% of the autosomal dominant polycystic kidney disease (ADPKD) population. Despite being an early and debilitating symptom, it is poorly characterized and management is suboptimal. This study aimed to develop an ADPKD-specific pain assessment tool (APAT) to facilitate pain research.

METHODS

Following a systematic review of PATs used in ADPKD studies and against international recommendations for pain trials, our multi-disciplinary team of clinical experts and patients constructed an ADPKD-pain conceptual framework of key pain evaluation themes. We compiled a new APAT covering domains prioritized within our framework using components of questionnaires validated in other chronic pain disorders. The APAT was administered longitudinally within a randomized high-water intake trial (NCT02933268) to ascertain feasibility and provide pilot data on ADPKD pain.

RESULTS

Thirty-nine ADPKD participants with chronic kidney disease Stages 1-4 provided 129 APAT responses. Each participant completed a median of 3 (range 1-10) assessments. Respondents' mean ± standard deviation age was 47 ± 13 years; 59% (23) were female; and 69% (27) had enlarged kidneys with median time from diagnosis 14.2 (interquartile range 7.0-25.9) years. Pain (52%) and associated analgesic use (29%) were common. Pain severity was associated with increasing age [odds ratio (OR) = 1.07, P = 0.009], female gender (OR = 4.34, P = 0.018), estimated glomerular filtration rate <60 mL/min/1.73 m2 (OR = 5.45, P = 0.021) and hypertension (OR = 12.11, P = 0.007), but not with kidney size (P = 0.23). The APAT achieved good internal consistency (Cronbach's alpha coefficient = 0.91) and test-retest reliability (domain intra-class correlation coefficients ranging from 0.62 to 0.90).

CONCLUSIONS

The APAT demonstrated good acceptability and reliability, and following further validation in a larger cohort could represent an invaluable tool for future ADPKD pain studies.

Management of simple renal cyst in children: French multicenter experience of 36 cases and review of the literature

OBJECTIVE

The widespread use of renal ultrasonography has resulted in simple renal cysts (SRC) being discovered with increasing frequency in routine pediatric urological practice. Management of SRC, however, remains controversial. Most SRC are asymptomatic, are diagnosed incidentally, and have no clinical consequence. Our goal was to focus on management strategies for SRC in children with the support of our experience and a review of the literature.

MATERIALS AND METHODS

A literature review was made of SRC in children since 1950, analyzing epidemiologic data, diagnosis, and management. In addition, a retrospective multicenter study was conducted from 1998 to 2009. Patients included presented with a unique SRC. Data recorded were patient characteristics (age, gender), symptoms, imaging features of the cyst (size, side, pole, and location), type of management, and long-term outcomes. To focus on management, two groups of patients were defined: primary surgical management and primary conservative management consisting of clinical and US follow-up. Our results were compared with the literature.

RESULTS

Thirty-six cases were included. Fifteen patients were symptomatic. Comparing the two groups, long-term outcomes were similar. The only significant factors were preoperative (age of the patient, diameter and location of the cyst): the bigger the cyst, the more likely it was to be exorenal, and the greater the likelihood that surgery would be performed (p = 0.006). Symptoms were not a significant indicator for surgery.

CONCLUSION

According to the literature and our experience, and considering the benign natural history of SRC and the similar outcomes whatever the treatment, primary conservative management is recommended for all cases. Surgery should be restricted to symptomatic large compressive cysts, increase in cyst size on follow-up, and uncertain diagnosis. Percutaneous cyst aspiration with sclerotherapy has not yet been used enough to ascertain its safety, and requires prospective evaluation.

Which Stage of ADPKD Is More Appropriate for Decortication? A Retrospective Study of 137 Patients from a Single Clinic

OBJECTIVE

To study retrospectively the efficacy of decortication in patients with different stages of ADPKD and to determine which stage for decortication is more appropriate.

MATERIALS AND METHODS

We analyzed 137 patients with ADPKD from 2001 to 2010. All patients were divided into three stages. A total of 70 patients underwent decortication, and we studied intraoperative indicators and postoperative indicators at 1 and 3 years follow-up.

RESULTS

In 70 patients who underwent decortication, significant differences were observed in operative duration and bleeding volume between patients with stage I and II ADPKD (P<0.05), but no significant differences were observed in intestinal recovery time, pain medication dose, and the days of postoperative hospitalization (P > 0.05). The total complication occurrence rate was significantly different between them (P < 0.05). The serum creatinine (Scr) levels in patients with stage I ADPKD were within normal limits 1 and 3 years postoperatively and did not differ significantly (P > 0.05). Scr levels were significantly decreased in patients with stage II ADPKD in the 1st postoperative year (P < 0.05), but these were not significant differences in the 3rd postoperative year (P > 0.05). In the 1st postoperative year, VAS value, blood pressure and renal volume significantly differed (P < 0.05). However, no significant differences were observed 3 years later (P > 0.05).

CONCLUSIONS

Decortication in patients with stage I ADPKD can alleviate back pain symptoms and decrease blood pressure within 1 year, but the long-term efficacy is not ideal. Scr levels can be maintained within normal limits, suggesting that decortication does not lead to deterioration of renal function. For patients with stage II ADPKD, decortication can significantly improve renal function over the short term. However, after 3 years, renal function returns to the preoperative level, and surgical difficulties and complications also increase.

[Place of laparoscopic cysts decortication (LCD) in the treatment of autosomal dominant polycystic kidney disease (AD PKD)]

INTRODUCTION

Decortication of many cysts in patients with autosomal dominant policystic kidney disease (AD PKD) allows to reduce renal mass, decreases hydrostatic pressure in cysts; moreover it diminishes pain.

METHODS

Between the years 2000-2005, 15 patients underwent laparoscopic cyst decortication (LCD) inculuding 5 (33.3%) men and 10 (66.7%) women. Patients age ranged between 41-73 years (mean 54 y.). Two patients underwent extraperitoneal and 13 transperitoneal LCD. In 2 patients were performed bilateral and in others unilateral decortication. LCD was done in 6 patients on the left side and in 7 on the right side. In all patients except three only 3 ports were used during these operations. Preoperative and postoperative diagnos was based on physical, laboratory, sonographic and computer tomografy (CT) examinations. Renal function was estimated by GFR and renal dynamic Tc99 scyntigraphy. Pain intensity was estimated in visual (VAS) 10 degree score. Follow-up after LCD was 9 to 77 months (mean 36 months).

RESULTS

The mean operative time and the mean hospitalization time were respectively: 197 minutes and 5,4 days. The mean convalescence time was 10.5 days. The mean number of operated cysts was 43,5 per one patient. Pain was relieved in all (100%) patients into 6 months after LCD but has returned in 20% patients after 12 months and in 27% patients after 24 months. Hypertension regressed in 4 patients among 6 (40.0%) with high blood pressure before operation, but haematuria regressed in all patients among 5 (33.3%) with this symptom before LCD. The mean renal function (GFR) increase was observed about 10%, but blood purification in scitiscanning about 4.9% in all patients.

CONCLUSIONS

(1) Laparoscopic cyst decortication (LCD) in patients with symptomatic AD PKD is safe, effective and repeatable alternative to non-radical open surgery. (2) LCD stabilizes renal function which together with improved renal perfusion and renal decontamination decreases number of severe, life-threatening complications.

[Cystic diseases of the kidney]

Cystic diseases of the kidney constitute a heterogeneous family. Most renal cysts are benign and asymptomatic, and don't have any impact on renal function. These "simple" cysts are usually managed conservatively. However, some renal cysts may be symptomatic or may have atypical radiological presentation, leading to suspicion of malignant tumour; puncture or surgical investigation may be indicated in such cases. The other cystic renal diseases include specific entities, either genetic or acquired during development. Some malformative syndromes are often associated, and renal function may be impaired. In such cases, nephrectomy is required.

A novel approach to bilateral hand-assisted laparoscopic nephrectomy for autosomal dominant polycystic kidney disease

PURPOSE

Laparoscopic nephrectomy in patients with autosomal dominant polycystic kidney disease (ADPKD) is technically challenging. We describe our technique and present our experience with a transperitoneal hand-assisted laparoscopic (HAL) technique using a standard vacuum curettage system to reduce the size of the kidneys thereby facilitating nephrectomy.

MATERIALS AND METHODS

A retrospective review was completed of 10 consecutive patients undergoing bilateral HAL nephrectomy between March 2002 and October 2004 using the following technique. A hand port is positioned through a 6-7 cm periumbilical incision and port sites are placed at the midclavicular line (12 mm) and anterior axillary line (5 mm) on the side of the initial nephrectomy. After the renal vessels are divided and the kidney is completely mobilized a 12 mm curette is inserted through the medial port site. The Berkeley VC-10 Vacuum Curettage System (ACMI, Southborough, MA) is used to morcellate and aspirate the kidney providing a significant decrease in the overall size and allowing easy extraction through the midline incision. The procedure is repeated for the contralateral side.

RESULTS

All 10 patients underwent successful bilateral HAL nephrectomy with a mean operative time of 194 minutes. The average length of stay was 4.7 days. Patients with renal allografts had stable function at the time of discharge. The average size of the kidneys removed was 717 g and average length was 19 cm. All patients did well postoperatively with complete resolution of their presenting symptoms.

CONCLUSION

In patients with symptomatic ADPKD, bilateral HAL nephrectomy using the vacuum curettage system to minimize the size of the kidneys is fast, safe and effective.

Bilateral hand-assisted laparoscopic nephrectomy for autosomal dominant polycystic kidney disease using a single midline HandPort incision

OBJECTIVES

To present one of the first known series of bilateral, transperitoneal laparoscopic nephrectomy for autosomal dominant polycystic kidney disease using a hand-assisted technique by way of a single, midline HandPort incision. Synchronous, bilateral nephrectomy for autosomal dominant polycystic kidney disease is an infrequently performed procedure, with only a few reports using laparoscopy.

METHODS

We retrospectively reviewed the charts of 4 patients undergoing bilateral hand-assisted laparoscopic nephrectomy for symptomatic autosomal dominant polycystic kidney disease between June 2000 and January 2001. Follow-up consisted of chart review and telephone survey.

RESULTS

All 4 patients underwent successful bilateral hand-assisted laparoscopic nephrectomy, with a mean operative time of 286 minutes. This included 1 patient who underwent simultaneous laparoscopic marsupialization of symptomatic hepatic cysts. The average size of the polycystic kidneys removed was 1582 g. Complications included acute tubular necrosis of a renal allograft in 1 patient that resolved spontaneously and retained retroperitoneal cystic fluid that required percutaneous drainage in another patient. All patients did well postoperatively, with complete resolution of their presenting symptoms. Those with renal allografts had stable function at the last follow-up visit.

CONCLUSIONS

Bilateral hand-assisted laparoscopic nephrectomy using a single HandPort incision is a feasible alternative for the removal of symptomatic polycystic kidneys. It offers the advantage of easier identification and control of hilar structures that are often obscured by the distorted renal anatomy. In addition, it allows the simultaneous performance of other intra-abdominal procedures.

Pain management in polycystic kidney disease

Pain is a common complaint in patients with autosomal-dominant polycystic kidney disease, and a systematic approach is needed to differentiate the etiology of the pain and define an approach to management. A thorough history is the best clue to the multifactorial causes of the pain, superimposed upon an understanding of the complex innervation network that supplies the kidneys. The appropriate use of diagnostic radiology (especially MRI) will assist in differentiating the mechanical low back pain caused by cyst enlargement, cyst rupture and cyst infection. Also, the increased incidence of uric acid nephrolithiasis as a factor in producing renal colic must be considered when evaluating acute pain in the population at risk. MRI is not a good technique to detect renal calculi, a frequent cause of pain in polycystic kidney disease. If stone disease is a possibility, then abdominal CT scan and/or ultrasound should be the method of radiologic investigation. Pain management is generally not approached in a systematic way in clinical practice because most physicians lack training in the principles of pain management. The first impulse to give narcotics for pain relief must be avoided. Since chronic pain cannot be "cured," an approach must include techniques that allow the patient to adapt to chronic pain so as to limit interference with their life style. A detailed stepwise approach for acute and chronic pain strategies for the patient with autosomal dominant polycystic kidney disease is outlined.

Transperitoneal laparoscopic nephrectomy for giant polycystic kidneys: a case control study

OBJECTIVES

To describe the technique and compare the surgical outcomes of patients with autosomal dominant polycystic kidney disease (ADPKD) undergoing laparoscopic or open nephrectomy for giant kidneys.

METHODS

The surgical outcome of our first 10 consecutive patients with ADPKD who underwent laparoscopic nephrectomy was analyzed from a large prospective computer database. The results were compared with the 10 most recent open nephrectomy procedures performed for ADPKD at the same institution. To facilitate safe laparoscopic hilar dissection, the kidneys were made manageable by volume reduction, accomplished through diligent cyst puncture and aspiration using a novel prototype suction device with a beveled tip.

RESULTS

No statistically significant differences were found between the laparoscopic and open surgical groups relative to patient sex, age, or median preoperative kidney size (24.0 versus 21.5 cm, respectively). The laparoscopic patients were significantly heavier than their open counterparts (94 versus 78 kg, P = 0.0095) and had a longer operative time (247 versus 205 minutes, P = 0.04). One conversion to open surgery occurred in the laparoscopic group because cysts were adherent to the spleen and colonic mesentery. No intraoperative complications or deaths occurred in either group and the postoperative complications were similar. The mean length of the postoperative hospitalization was markedly reduced with the laparoscopic compared with the open approach (2.6 versus 6.6 days, P = 0.00002). At a median of 12 months after surgery, none of the laparoscopic patients had recurrent pain, bleeding, or infection.

CONCLUSIONS

Laparoscopic nephrectomy is technically safe and feasible in patients with ADPKD. Progressive cyst aspiration is a critical step, facilitating the identification of vital structures and the creation of enough abdominal cavity space to operate. The advantages of this minimally invasive technique include a short hospital stay, minimal pain, low morbidity, and superior cosmesis.

Laparoscopic cyst marsupialization in patients with autosomal dominant polycystic kidney disease

PURPOSE

Autosomal dominant polycystic kidney disease is characterized by progressively enlarging renal cysts associated with hypertension, renal failure, pain, hematuria and infection. We explored the role of laparoscopic cyst marsupialization for managing cyst related problems.

MATERIALS AND METHODS

In 4 male and 11 female adults with autosomal dominant polycystic kidney disease who had preserved renal function laparoscopic cyst marsupialization was done for pain unilaterally and bilaterally in 9 and 6, respectively. An average of 204 cysts per kidney (range 11 to 635) were decorticated or drained.

RESULTS

Average operative time was 5.5 hours. Patients were discharged from the hospital after an average of 3.2 days. At a mean followup of 2.2 years (range 0.5 to 5) pain was decreased an average of 62% (range 30% to 90%) in 11 cases (73%). One patient had no improvement and 1 had subsequent worsening of pain postoperatively. Two patients with initial improvement had pain recurrence 4 and 36 months postoperatively, respectively. Hypertension resolved in 1 patient (7%), improved in 20% and did not change in 40%. In 33% of the cases hypertension worsened, requiring additional antihypertensive medication. Renal function remained stable in 13 patients (87%), improved in 1 (6.5%) and worsened in 1 (6.5%). Overall patients who underwent a bilateral procedure had better long-term pain relief and more improvement in hypertension.

CONCLUSIONS

Laparoscopic cyst marsupialization may effectively decrease cyst associated pain. In some cases hypertension may be improved. Renal function remained stable in all except 1 patient. At a mean followup of 2.2 years the benefits of aggressive laparoscopic cyst decortication appear to be relatively long lasting when bilateral decortication is indicated. The benefits of unilateral cyst decortication are less predictable and of shorter duration.

Laparoscopic bilateral synchronous nephrectomy for autosomal dominant polycystic kidney disease: the initial experience

PURPOSE

We report our experience with laparoscopic bilateral synchronous nephrectomy for giant symptomatic autosomal dominant polycystic kidney disease (ADPKD) and compare outcome data with open bilateral nephrectomy.

MATERIALS AND METHODS

Since March 1998, 10 patients underwent bilateral synchronous laparoscopic nephrectomy for giant symptomatic ADPKD. A 3 port retroperitoneal laparoscopic approach was used to secure the renal hilum and mobilize the kidney. Intact specimen extraction was performed through a midline infraumbilical extraperitoneal incision. The patient was then repositioned for the contralateral retroperitoneoscopic nephrectomy, with the second specimen also delivered through the same infraumbilical incision. Data were retrospectively compared with 10 patients who had undergone bilateral synchronous open nephrectomy for ADPKD between 1981 and 1992.

RESULTS

Patients in the laparoscopic and open groups were comparable in regard to age (53 versus 47 years, p = 0.54) and Anesthesiologist Society of America class (3 versus 3, p = 0.84) but patients in the laparoscopic group were significantly more obese (body mass index 35.9 versus 23.8, p = 0.02). For comparable total specimen weights (3 versus 3 kg, p = 0.69) surgical time was longer in the laparoscopic group (4.4 versus 3.8 hours, p = 0.007). However, the laparoscopic group was superior in regard to blood loss (150 versus 325 cc, p = 0.05), postoperative requirement of nasogastric tube (10% versus 100%, p = 0.0001), narcotic analgesics (34.2 versus 120.4 mg. morphine sulfate equivalent, p = 0.03) and hospital stay (1.5 versus 9 days, p = 0.004). Complications occurred in 5 patients (50%) in the laparoscopic group and 4 (40%) in the open group (p = 0.66). No laparoscopic case was converted to open surgery.

CONCLUSIONS

Synchronous bilateral retroperitoneal laparoscopic nephrectomy for giant symptomatic adult polycystic kidney disease is feasible, safe and efficacious, and can be performed either before or after renal transplantation. Compared to open surgery, the laparoscopic approach results in significantly shorter hospital stay, decreased morbidity and quicker recovery. Laparoscopy is currently our technique of choice in this setting.

Polykystose rénale siège d'aspergillose traitée par néphrectomie rétropéritonéale laparoscopique

We reported an uncommon case of 40 years old man, cardiac transplant recipient with chronic renal faillure who consulted for infected left polycystic renal. The serum creatinine level was 750 mmol/L, and urine culture isolated a E. Ecol germe. The abdominopelvic computed tomography showed a bilateral large polycystic renal cortex and suspected the infected cyst in lower pole of left kidney. The retroperitoneal laparoscopic nephrectomy was performed confirming a renal invasive aspergillosa. About this case we should have a high index of suspicion for fungal aetiology in kidney infection in transplant patients and the management of non functioning infected polycystic kidney can use laparoscopic retroperitoneal nephrectomy. This approach can offers a minimal morbidity and alternative to open surgery.

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.

Value of laparoscopy in the management of calculi complicating renal malformations

A minimally invasive approach for urolithiasis patients with complex anatomic abnormalities occasionally necessitates the use of laparoscopic techniques, either alone or in combination with endourologic techniques. The management of these patients is best accomplished in centers with the facilities to provide a spectrum of endourologic and laparoscopic techniques. Two illustrative cases are described.

Laparoscopy for adult polycystic kidney disease: a promising alternative

The purpose of this study was to evaluate the efficacy of laparoscopy in managing patients with abdominal symptoms from autosomal dominant polycystic kidney disease (ADPKD). From April 1993 to July 1995, four patients with ADPKD underwent seven laparoscopic procedures: five cyst decortications were performed in two patients using a laparoscopic ultrasound unit and two laparoscopic nephrectomies were performed in two patients with end-stage renal failure. The mean operative time was 207 minutes for laparoscopic cyst decortication and 272 minutes for laparoscopic nephrectomy. The two nephrectomy specimens were 2,200 g and 1,750 g, respectively. The mean intraoperative blood loss was 85 mL. The patients resumed their oral intake within 10 hours after laparoscopic cyst decortication and within 16 hours after laparoscopic nephrectomy. The mean amount of parenteral analgesics required postoperatively was 12 mg morphine sulfate for cyst decortication and 30 mg morphine sulfate for nephrectomy. The mean hospital stay was 3 days for cyst decortication and 3.5 days for nephrectomy. The patients returned to their usual activities after an average of 2 weeks. Based on pain analog scales, all the patients have shown marked reduction in their symptoms (average, 90%) during an average follow-up period of 6.6 months. Laparoscopic cyst decortication and nephrectomy are effective minimally invasive treatment options for patients with adult polycystic kidney disease who are experiencing abdominal symptoms due to marked renal enlargement. We believe that by using a laparoscopic ultrasound unit, most renal cysts may be safely removed, and if need be, even "giant" kidneys can be removed laparoscopically. To the best of our knowledge, the two nephrectomy specimens in this study represent the largest kidneys removed laparoscopically to date and the first laparoscopic nephrectomies in ADPKD patients.