Laparoscopic management of indeterminate renal cysts

A case involving laparoscopic decortication of a large simple renal cyst using conventional monopolar device

Introduction and importance

Simple renal cysts are common in adults, but most of them are asymptomatic. Usually, percutaneous puncture is an initial treatment, but laparoscopic decortication may be effective for recurrent simple renal cyst. Herein, we report a case in which a large symptomatic simple renal cyst was treated with laparoscopic decortication using conventional monopolar device.

Case presentation

A 34-year-old female visited our hospital with chief complaints of back pain and abdominal fullness. Computed tomography showed a right simple renal cyst (diameter: 140 mm). We performed percutaneous drainage with sclerotherapy, but the cyst recurred a month later. Thus, we carried out laparoscopic decortication. We opened the cyst wall via a retroperitoneal approach and trimmed it using monopolar scissors. The operation time was 124 min. The patient's postoperative course was uneventful, and no complications were observed. Following surgery, the patient was asymptomatic.

Clinical discussion

In our case, we performed operation using a conventional monopolar device without sealing devices. It has been reported that the use of sealing devices can make laparoscopic surgery safer and reduce the operation time, but we herein report that laparoscopic decortication with a conventional monopolar device is an effective and safe treatment option for symptomatic simple renal cysts and that more expensive energy sources are not required.

Conclusion

We successfully performed laparoscopic decortication of a large symptomatic simple renal cyst. This operation is minimally invasive and safe.

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Simple renal cyst are common and most cases are asymptomatic, but large simple renal cyst may cause symptoms such as pain.

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As an initial treatment, percutaneous puncture is widely performed, but recurrence rates are high.

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Laparoscopic decortication may be an effective and safe treatment option for large symptomatic simple renal cysts.

Partial nephrectomy for a Bosniak IV cystic renal mass mimicking a simple renal cyst adjacent to a solid renal tumor

INTRODUCTION

Renal tumors are often associated with renal cysts. Meanwhile, in some cases there are challenging issues of how to diagnose renal cystic tumors and to decide surgical procedures.

CASE PRESENTATION

A 75-year-old man was referred to our department for a 21-mm tumor by his left kidney. Contrast-enhanced computed tomography showed an intense contrast uptake the tumor, which was adjacent to a 64-mm unilocular renal cyst with no contrasting effects. It was clinically diagnosed as renal cell carcinoma, stage T1aN0M0, and treated with robot-assisted partial nephrectomy, for both the solid tumor and the adjacent cyst. Pathological findings revealed a tumor cell clump within the cyst wall, concurrent with the renal cell carcinoma. The patient has remained free of disease at 1 year after surgery.

CONCLUSION

A partial nephrectomy that includes the entire cyst wall should be considered for renal tumor associated with unilocular renal cyst.

Imaging-guided radiofrequency ablation of cystic renal neoplasms

OBJECTIVE

The purpose of this article is to determine whether percutaneous radiofrequency ablation (RFA) is effective and safe for the treatment of cystic renal neoplasms.

MATERIALS AND METHODS

This is a retrospective review of imaging-guided RFA of Bosniak III and IV cysts from one institution. Thirty-eight subjects (19 men and 19 women; mean age, 71 years; age range, 46-95 years) underwent RFA of 40 cystic neoplasms (Bosniak III, n = 25; Bosniak IV, n = 15). Percutaneous biopsy was performed in 90% (36/40) of lesions. For patients with imaging follow-up of at least 1 year (n = 21), the mean duration of surveillance was 2.8 years (range, 1-6.5 years). The electronic medical record was reviewed for complications related to the procedure. Estimated glomerular filtration rate (GFR) was measured before RFA and at the last follow-up visit more than 6 months after the RFA session.

RESULTS

According to percutaneous biopsy, 61.1% (22/36) of lesions were malignant, and 38.9% (14/36) of biopsies were inconclusive. There was no local tumor progression, and no subjects developed metastatic disease. One subject developed a new solid renal mass during the course of follow-up. Minor complications occurred in 5.3% (2/38) of ablations and included dysuria and mild hydronephrosis related to a blood clot in the ureter. There was one major complication (2.6%), a case of flash pulmonary edema. On average, estimated GFR decreased by 2.5 mL/min/1.73 m(2).

CONCLUSION

Imaging-guided RFA is an effective and safe treatment of Bosniak III and IV cystic renal neoplasms with outcomes comparable to those of surgical therapies.

Renal cell carcinoma : clinical features and management

In 1999 it was estimated that renal cell carcinoma (RCC) would account for 29,990 new cancer cases diagnosed in the United States (61% in men and 39% in women), and lead to 11,600 deaths. RCC accounts for 2-3% of all malignancies in adults and causes 2.3% of all cancer deaths in the United States annually (1). Approx 4% of all RCC cases are bilateral at some point in the life of the patient. Data from over 10,000 cases of renal cancer entered in the Connecticut Tumor Registry suggests an increase in the incidence of renal cancer from 1935-1989; in women the incidence increased from 0.7 to 4.2 in 100,000, and in men from 1.6 to 9.6 in 100,000 (2). Factors implicated in the development of RCC include cigarette smoking, exposure to petroleum products, obesity, diuretic use, cadmium exposure, and ionizing radiation (3-9).

Laparoendoscopic single-site surgery for symptomatic renal cyst decortication using a homemade glove port device: initial experience

OBJECTIVES

Laparoendoscopic single-site surgery (LESS) has recently gained popularity in urology. There are few large series reports on LESS for symptomatic renal cysts. We evaluated the clinical utility and safety of LESS in 62 symptomatic renal cyst decortication patients by using a homemade glove port device.

MATERIALS AND METHODS

We reviewed our series of 62 LESS for symptomatic renal cyst (20 Bosniak type I and 42 Bosniak type II) decortication performed from November 2009 to December 2010. A homemade glove port device was placed through an umbilical incision. The perioperative clinical parameters were reviewed retrospectively.

RESULTS

Of 62 cases that underwent LESS for renal cyst ablation successfully, there were no major perioperative complications, but 2 minor complications (transient fever and mild ileus) were found. The mean operative time was 61.4 ± 27.4 min and the mean estimated blood loss was 20.1 ± 11.3 ml. The mean pre- and postoperative pain scores were 6.94 ± 1.1 (range 5-10) and 1.3 ± 1.2 (0-5), respectively (p = 0.000).

CONCLUSIONS

Our results suggest that LESS is a safe and feasible alternative to conventional laparoscopic surgery for the treatment of symptomatic renal cysts.

Laparoscopic decortication of symptomatic simple renal cyst using conventional monopolar device

In our study, we assessed the efficacy, safety, and feasibility of laparoscopic decortication of symptomatic simple renal cysts using conventional monopolar device. Long-term symptomatic and radiological results of 15 patients who underwent laparoscopic renal symptomatic simple cyst decortication, which was performed by conventional monopolar device, were retrospectively reviewed. The mean age of the patients was 49.7 years. There were nine male and six female patients. Their presenting symptoms were lumber pain in 93% (n=14), and hypertension in 7% (n=1). The mean operating time was 64.6 minutes. The mean hospital stay was 2.2 days. After a mean follow up of 12.08 months, the radiological and symptomatic successes were 100% and 86.6%, respectively. Laparoscopic renal cyst decortication using conventional monopolar device represents an effective and safe treatment option in the management of renal cyst without any need for more expensive energy sources.

[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.

[Evaluation and prognostic of cystic renal tumors]

OBJECTIVE

To evaluate the clinical and pathological characteristics of cystic renal tumors in our center.

MATERIAL AND METHODS

A retrospective review of 239 nephrectomies is performed comparing the clinical and pathological variables of cystic tumors with those of solid renal tumors. Survival outcomes are analyzed in both groups.

RESULTS

Our experience shows that cystic renal tumors behave like solid renal tumors, with no differences in survival shown. The variables studied show statistically significant differences in histological grade and number of tumors, with cystic tumors having a lower histological grade and being more often multiple in number.

CONCLUSIONS

The behavior of cystic renal tumors is no different than that of solid renal tumors.

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.

Laparoscopic ablation of symptomatic parenchymal and peripelvic renal cysts

OBJECTIVES

To assess the safety and efficacy of laparoscopic ablation of symptomatic renal cysts as minimally invasive therapeutic techniques have largely supplanted open surgical intervention for the treatment of symptomatic renal cysts.

METHODS

The records of 32 consecutive adult patients who underwent laparoscopic ablation of renal cysts (11 peripelvic, 21 parenchymal) were retrospectively reviewed. All patients were symptomatic at presentation; 26 had a single cyst, 5 had two cysts, and 1 had four cysts.

RESULTS

Twenty patients underwent a transperitoneal laparoscopic approach, and 12 patients underwent a retroperitoneal laparoscopic approach. An average of 3.2 ports were used for each procedure, and no open conversions or transfusions were necessary. When comparing patients with parenchymal and peripelvic cysts, statistically significant differences were noted in the mean operative time (164 versus 233 minutes, respectively; P = 0.003) and mean operative blood loss (98 versus 182 mL, respectively; P = 0.04). Four patients (13%) had complications (one major and three minor), including a persistent ureteral stricture. One patient with negative preoperative aspiration cytology and negative intraoperative frozen section analysis was later found to have malignancy within the cyst wall, necessitating radical nephrectomy and trocar site excision. One patient (3%) developed a recurrence.

CONCLUSIONS

Laparoscopic ablation of symptomatic renal cysts is a safe and efficacious procedure. We report an overall complication rate of 13% and a recurrence rate of 3% with a mean follow-up of 18.1 months (median 10.0).

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.

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.

Partial nephrectomy with retroperitoneal laparoscopy

PURPOSE

Laparoscopy has gradually gained acceptance for a variety of ablative procedures of the retroperitoneal organs, and the indications are being extended to more complex reconstructive and organ preserving procedures. We report our experience with retroperitoneal laparoscopic partial nephrectomy.

MATERIALS AND METHODS

Retroperitoneal laparoscopic partial nephrectomy was performed for benign conditions in 6, equivocal solid masses in 4 and indeterminate cysts in 3 patients. If malignancy was suspected, laparoscopic sonography was used to assess the intrarenal anatomy and the mass. To facilitate parenchymal closure during nephron sparing surgery we used a hemostatic biological glue that consisted of gelatin, resorcinol and formaldehyde.

RESULTS

Average operating time was 113 minutes and average blood loss was 72 ml. Histological examination revealed malignancy in 1 of the 3 cystic lesions and 2 of the 4 equivocal solid masses. There were 2 postoperative urinomas.

CONCLUSIONS

Partial nephrectomy with retroperitoneal laparoscopy is feasible, and has a reasonable operating time and blood loss. Laparoscopic ultrasound was an important decision making aid during surgery. The use of biological glue simplified hemostasis and closure of the collecting system but good quality drainage of the collecting system is still required to decrease the risk of urinoma. The development of surgical tools that allow bloodless and nontraumatic section of the renal parenchyma is required to facilitate laparoscopic nephron sparing surgery. The ultrasonic scalpel needs further evaluation in this setting.

Is open surgery for partial nephrectomy an obsolete surgical procedure?

During the past few years, the indications for laparoscopic surgery in urology have extended from simple ablative procedures towards more complex reconstructive and organ-preserving interventions. Among them, transperitoneal and extraperitoneal laparoscopic partial nephrectomy have been successfully performed for both benign and malignant lesions. However, this approach raises specific problems because in contrast to other laparoscopic procedures the techniques and tools used during open surgery can not be simply transposed to laparoscopy. The absence of surface hypothermia, the lack of manual palpation, difficulties of vascular control and reconstruction of the collecting system necessitate new solutions readily adaptable to laparoscopic surgery. However, the available series comprise only a few cases, and there are differences in techniques and instrumentation in almost every operation. In these circumstances, it is too early to consider this new approach as reproducible and ready to be used elsewhere than in specialized centres. Although the feasibility and good results of partial nephrectomy for benign conditions and small exophitic tumours is now well documented, the development of new surgical tools and standardization of methodology are required for more complex cases within the scope of well conceived prospective studies.