Pretransplant laparoscopic nephrectomy in adult polycystic kidney disease: a single centre experience

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.

Introduction of laparoscopic nephrectomy for autosomal dominant polycystic kidney disease as the standard procedure

PURPOSE

Autosomal dominant polycystic kidney disease (ADPKD) is a common hereditary disorder and accounts for 5-10% of all cases of kidney failure. 50% of ADPKD patients reach kidney failure by the age of 58 years requiring dialysis or transplantation. Nephrectomy is performed in up to 20% of patients due to compressive symptoms, renal-related complications or in preparation for kidney transplantation. However, due to the large kidney size in ADPKD, nephrectomy can come with a considerable burden. Here we evaluate our institution's experience of laparoscopic nephrectomy (LN) as an alternative to open nephrectomy (ON) for ADPKD patients.

MATERIALS AND METHODS

We report the results of the first 12 consecutive LN for ADPKD from August 2020 to August 2021 in our institution. These results were compared with the 12 most recent performed ON for ADPKD at the same institution (09/2017 to 07/2020). Intra- and postoperative parameters were collected and analyzed. Health related quality of life (HRQoL) was assessed using the SF36 questionnaire.

RESULTS

Age, sex, and median preoperative kidney volumes were not significantly different between the two analyzed groups. Intraoperative estimated blood loss was significantly less in the laparoscopic group (33 ml (0-200 ml)) in comparison to the open group (186 ml (0-800 ml)) and postoperative need for blood transfusion was significantly reduced in the laparoscopic group (p = 0.0462). Operative time was significantly longer if LN was performed (158 min (85-227 min)) compared to the open procedure (107 min (56-174 min)) (p = 0.0079). In both groups one postoperative complication Clavien Dindo ≥ 3 occurred with the need of revision surgery. SF36 HRQol questionnaire revealed excellent postoperative quality of life after LN.

CONCLUSION

LN in ADPKD patients is a safe and effective operative procedure independent of kidney size with excellent postoperative outcomes and benefits of minimally invasive surgery. Compared with the open procedure patients profit from significantly less need for transfusion with comparable postoperative complication rates. However significant longer operation times need to be taken in account.

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.

Laparoscopic Nephrectomy for Massive Kidneys in Polycystic Kidney Disease

Background and Objectives:

Laparoscopic nephrectomy is now considered a feasible surgical approach, even for large kidneys. In the case of massive kidneys, laparoscopy can be problematic, so that some authors suggest an open approach. However, previous studies have shown that hand-assisted laparoscopic nephrectomy (HALN) may represent a useful compromise.

We describe our hand-assisted laparoscopic technique for nephrectomy of large kidneys (> 2500 g) to encourage the use of laparoscopy for nephrectomy in autosomal dominant polycystic kidney disease.

Methods:

We retrospectively analyzed data from 26 nephrectomies in 17 patients who underwent HALN for ADPKD and compared them to a group of 22 nephrectomies in 18 patients with open surgical technique.

Results:

The duration of the procedure was significantly longer in the laparoscopic group, with a median of 180 minutes versus 90 minutes for the unilateral nephrectomies, and 240 minutes versus 122 minutes for the bilateral procedures. The median kidney weight in the open group was 2500 g (range 1300 – 4500 g), while the median weight in the HALN group was 2375 g (range 1000 – 4700 g). The median hospital stay was comparable. No significant differences were recorded in the intra- and postoperative complication rate.

Conclusion:

Hand-assisted laparoscopic nephrectomy can be considered a technique of choice for patients suffering from ADPKD requiring nephrectomy, also with massive kidneys weighing more than 3500 g. Compared to open nephrectomy, HALN can be performed safely, with reasonably longer operating times and without major complications, and offers a significant reduction in hospitalization time, pain and postoperative discomfort.

Predictors and outcomes of laparoscopic nephrectomy in autosomal dominant polycystic kidney disease

Purpose

Autosomal dominant polycystic kidney disease (ADPKD) is the most common hereditary kidney disease, and 20% of patients eventually require nephrectomies due to compressive symptoms or renal-related complications. Traditionally, nephrectomies were performed via the open approach in view of space constraints. We evaluate our institution's outcomes for laparoscopic nephrectomy (LN) for ADPKD.

Materials and Methods

We retrospectively reviewed 33 patients with ADPKD who underwent nephrectomies from November 2005 to December 2016 at a tertiary institution. Preoperative kidney volume was calculated via the ellipsoid method by using computed tomography scan.

Results

The median age was 51.0 years (interquartile range [IQR], 44.5–56.0 years). Sixteen patients (48.5%) underwent open nephrectomy (ON), 15 patients (45.5%) had LNs, and 2 patients (6.1%) had laparoscopic converted to ON due to dense adhesions. Thirteen patients had bilateral while 18 patients had unilateral nephrectomies. Median kidney volume in the open group was 1,042 cm³ (IQR, 753–2,365 cm³) versus 899 cm³ (IQR, 482–1,914 cm³) in the laparoscopy group and did not differ significantly. The operative time was comparable between both groups. Patients who underwent LN had lesser blood loss (350 mL vs. 650 mL; 95% confidence interval [CI], 1.822–3.533; p=0.016) and shorter length of hospital stay (4.0 days vs. 6.5 days; 95% CI, 1.445–5.755; p=0.001) compared to patients who underwent ON. Both groups had similar low morbidity rate and no mortality.

Conclusions

LN for ADPKD is a safe and effective alternative to ON independent of kidney size with comparable outcomes and benefits of minimally invasive surgery.

Live Donor Renal Transplant With Simultaneous Bilateral Nephrectomy for Autosomal Dominant Polycystic Kidney Disease Is Feasible and Satisfactory at Long-term Follow-up

BACKGROUND

Timing of bilateral nephrectomy (BN) is controversial in patients with refractory symptoms of autosomal dominant polycystic kidney disease (APKD) in need of a renal transplant.

METHODS

Adults who underwent live donor renal transplant (LRT) + simultaneous BN (SBN) from August 2003 to 2013 at a single transplant center (n = 66) were retrospectively compared to a matched group of APKD patients who underwent LRT alone (n = 52). All patients received general health and polycystic kidney symptom surveys.

RESULTS

Simultaneous BN increased operative duration, estimated blood loss, transfusions, intravenous fluid, and hospital length of stay. Most common indications for BN were pain, loss of abdominal domain, and early satiety. There were more intraoperative complications for LRT + SBN (6 vs 0, P = 0.03; 2 vascular, 2 splenic, and 1 liver injury; 1 reexploration to adjust graft positioning). There were no differences in Clavien-Dindo grade I or II (39% vs 25%, P = 0.12) or grade III or IV (7.5% vs 5.7%, P = 1.0) complications during the hospital course. There were no surgery-related mortalities. There were no differences in readmission rates (68% vs 48%, P = 0.19) or readmissions requiring procedures (25% vs. 20%, P = 0.51) over 12 months. One hundred percent of LRT + SBN allografts functioned at longer than 1 year for those available for follow-up. Survey response rate was 40% for LRT-alone and 56% for LRT + SBN. One hundred percent of LRT + SBN survey responders were satisfied with their choice of having BN done simultaneously.

CONCLUSIONS

Excellent outcomes for graft survival, satisfaction, and morbidity suggest that the combined operative approach be preferred for patients with symptomatic APKD to avoid multiple procedures, dialysis, and costs of staged operations.

Laparoscopic nephrectomy for autosomal dominant polycystic kidneys in patients with end-stage renal disease on maintenance hemodialysis: 10-year single surgeon experience from an Indian center

CONTEXT

Pure laparoscopic nephrectomy in patients with ADPKD (autosomal dominant polycystic kidney disease) and ESRD (end-stage renal disease) on MHD (maintenance hemodialysis) is challenging with high incidence of complications. Limited experiences from India has been reported in these scenarios.

AIMS

To present a 10-year single surgeon experience from India in laparoscopic nephrectomy in autosomal dominant polycystic kidneys (ADPKD) and end-stage renal disease (ESRD) on maintenance hemodialysis (MHD).

SETTINGS AND DESIGN

Retrospective.

MATERIALS AND METHODS

Retrospective analysis of records of similar subset of patients who were offered laparoscopic nephrectomy between 2003 and 2012. Preoperative, operative and postoperative parameters were recorded. Few technical modifications were adopted over the years. Patients were sub-classified into two groups (Group I: 2003-2006, Group II: 2007-2012) based on surgical technique.

STATISTICAL ANALYSIS USED

SAS software 9.1 version.

RESULTS

75 patients (84 renal units, Group I: 31, Group II: 53) were included in this analysis. Unilateral procedure was performed in 66 and bilateral staged or simultaneous procedure in 9. Despite larger kidneys in Group II (mean longitudinal renal length 25.7 ± 3.4 vs 17.5 ± 2.7 centimeters, P <0.001), improved operative and postoperative profile were noted in Group II in several parameters-mean total operative time (205 ± 11.5 vs 310 ± 15.3 min, P = 0.00), time for specimen retrieval (30.5 ± 3.5 vs 45 ± 4.1 min, P = 0.02), postprocedure drop in hemoglobin (1.1 ± 0.1 vs 2.27 ± 0.03 grams/deciliter, P = 0.00). Conversion rates, intraoperative and postoperative events were also considerably less in Group II.

CONCLUSIONS

Despite existence of comorbidities and technical difficulties, laparoscopic nephrectomy in patients with ADPKD with ESRD and on MHD is a feasible option. Technical modifications with increasing surgeon's experience allows successful conductance of this approach in more complex cases with better outcome.

Laparoscopic Nephrectomy versus Open Nephrectomy for Patients with Autosomal Dominant Polycystic Kidney Disease: A Systematic Review and Meta-Analysis

Objective

To compare efficacy and safety of laparoscopicnephrectomy (LN) versusopen nephrectomy (ON) in the management of autosomal dominant polycystic kidney disease (ADPKD), we conducted a systematic review and meta-analysis.

Methods

A systematic search of the electronic databases PubMed, Scopus, and the Cochrane Library was performed up to October 2014.This systematic review was performed based on observational comparative studies that assessed the two techniques. The weighted mean difference (WMD) and risk ratio (RR), with their corresponding 95% confidence interval (CI), were calculated to compare continuous and dichotomous variables, respectively.

Results

Seven studies were identified, including 195 cases (118 LN / 77 ON). Although LN was associated with longer operative time (WMD 30.236, 95%CI 14.541 −45.932, P<0.001) and the specimen might not have been resected as heavy as the ON group (WMD -986.516, 95%CI -1883.24–-89.795, P = 0.031), patients in this group might benefit from a shorter length of hospital stay (WMD -3.576, 95%CI 4.976–-2.176, P <0.001), less estimated blood loss (WMD -180.245, 95%CI -317.939–-42.556, P = 0.010), and lower need of transfusion (RR 0.345, 95%CI 0.183–0.650, P = 0.001). The LN group also had less overall complications (RR 0.545, 95%CI 0.329–0.903, P = 0.018). The need of narcotic analgesics between the two groups might have no significant difference (WMD -54.66, 95%CI -129.76–20.44, P = 0.154).

Conclusion

LN for giant symptomatic ADPKD was feasible, safe and efficacious. Morbidity was significantly reduced compared with the open approach. For an experienced laparoscopist, LN might be a better alternative.

Pure laparoscopic unilateral nephrectomy for a patient with a polycystic horseshoe kidney

A 45-year-old female patient with autosomal dominant polycystic kidney disease (ADPKD) and a horseshoe kidney underwent right laparoscopic nephrectomy. The indication for nephrectomy was to create space within the right iliac fossa for renal transplantation. The operation proceeded as routine for laparoscopic nephrectomy for ADPKD, but was uniquely challenging due to the large size and extensive vasculature of the polycystic horseshoe kidney. In addition to documenting the feasibility of the pure laparoscopic approach for nephrectomy in patients with ADPKD and horseshoe kidney, this case highlights the abnormal location and vasculature encountered when operating on horseshoe kidneys.

Laparoscopic nephrectomy for massive polycystic kidney disease: Updated technique and outcomes

INTRODUCTION

We present our technique of laparoscopic nephrectomy for massive polycystic kidneys in patients with autosomal dominant polycystic kidney disease (ADPKD) and review the outcome analysis of our experience.

METHODS

We retrospectively reviewed all transperitoneal laparoscopic nephrectomies done for polycystic kidneys at a university hospital. Our technique included three 12-mm ports with additional one or two 5-mm ports, with usage of retraction devices, such as the Jarit PEER retractor (J. Jamner Surgical Instruments, Inc, Hawthorne, NY).

RESULTS

In total, 39 (left 14, right 25) laparoscopic nephrectomies were performed in 32 patients (male 21, female 11). Surgical indications were varied: to create space for future renal transplant in 21 (54%), to alleviate pain in 16 (41%), to prevent recurrent urosepsis in 2 (5%), to prevent recurrent bleeding which would require transfusions in 2 (5%) and to remove a renal tumour in 1 kidney (2.5%). Four patients had surgery for more than one reason. The mean age and body mass index were 52.2 years (range: 29-72) and 26.9 kg/m(2) (range: 21.6-34.0), respectively. The mean preoperative hemoglobin and serum creatinine levels were 131.6 g/L (range: 107-171) and 514 µmol/L (range: 84-923), respectively; 26 (81%) patients were on dialysis. The mean operative time and estimated blood loss were 185 minutes (range: 113-287) and 94 mL (range: 10-350), respectively. No patient required open conversion. The mean specimen size was 24.2 cm (range: 15-38); weight 1515 g (range: 412-4590) and the length of extraction incision was 9.2 cm (range: 6-13). There were 1 Grade 2 2 (2.5%), 2 Grade 3b (5%) and 1 Grade 4a-d (2.5%) complications. The mean length of stay was 4.5 days (range: 3-8).

CONCLUSIONS

Our technique of laparoscopic nephrectomy for massively enlarged polycystic kidneys in ADPKD is safe and offers all the advantages of minimal access surgery, such as smaller incision, decreased estimated blood loss, excellent cosmesis and faster recovery.

Laparoscopic pretransplant nephrectomy with morcellation in autosomic-dominant polycystic kidney disease patients with end-stage renal disease

BACKGROUND

Laparoscopic nephrectomy (LN) in end-stage autosomic-dominant polycystic kidney disease (ADPKD) requires a large abdominal incision for the specimen extraction.

OBJECTIVE

The objective of this study was to describe our technique of LN for end-stage ADPKD followed by morcellation (LNM) of the specimen and extraction through a minimal abdominal incision.

METHODS

The medical records of 19 consecutive patients who underwent pretransplant LNM between 2008 and 2011 by a single experienced laparoscopic surgeon were analyzed. Morcellation was performed with the Gynecare Morcellex™ Tissue morcellator, Ethicon.

RESULTS AND LIMITATIONS

All cases but one were completed laparoscopically. Mean specimen weight was 1,026.8 g. Mean duration of the procedure, estimated blood loss, and hospital stay were 131.3 min, 52.1 ml, and 7.9 days, respectively. Specimens were extracted through a 12-mm trocar in 10/18 patients and through a 3-cm incision in 9/18 cases. Postoperatively, three complications were observed (Clavien grades II, I, and II). The only case of incisional hernia was observed in the converted procedure. Major limitation of the study is its retrospective design.

CONCLUSIONS

In our preliminary series and in the hands of a very experienced laparoscopist, LNM for ADPKD appears as a modern, mini-invasive, and safe technique. Specimen's extraction through a small abdominal incision reduces postoperative pain and incisional hernias and guarantees the final cosmetic result of laparoscopy. The reduced overall morbidity could reduce the period between nephrectomy and transplantation.

Transperitoneal laparoscopic nephrectomy for autosomal dominant polycystic kidney disease

Compared to open surgery, laparoscopic nephrectomy for autosomal dominant polycystic kidney disease appears to be a feasible and safe approach.

Objective:

This study focuses on laparoscopic nephrectomy for autosomal dominant polycystic kidney disease (ADPKD).

Material and Methods:

We retrospectively reviewed 21 consecutive patients who had previously undergone laparoscopy between 2007 and 2010. Data were compared to that obtained from 19 consecutive patients who had open surgery between 2004 and 2007. Clinical parameters, operative data, perioperative mortality, postoperative complications, and length of hospital stay were compared using χ² and Student t tests for qualitative and quantitative variables, respectively.

Results:

Nephrectomy is usually performed to create space for renal transplantation (81% and 79%, respectively). Operating time was longer with the laparoscopic approach (180 min vs. 128 min, P = .001). Blood loss was comparable in the 2 groups (154 vs. 222 ml, P = .359) but 3 patients were transfused in the open surgery group as compared with 1 patient in the laparoscopic group. No conversion was needed. There was a trend in the laparoscopic group with respect to lower consumption of analgesics in the postoperative period (P = .06). Delay to transit recovery (2.1 d vs 4.1 d, P < .001) and hospital stay (5.2 d vs. 8.28 d, P = .002) were significantly decreased in the laparoscopic group. The interval from surgery to renal transplantation was lower in patients operated on laparoscopically (3.1 vs. 12 mo). Complications occurred in 33% of the patients in the laparoscopic group as compared with 68% in the open surgery group (P = .22). Severe complications were less frequent in the laparoscopic group (9.5% vs. 37%, P = .04).

Conclusion:

Laparoscopic nephrectomy is a feasible and safe procedure for ADPKD. Morbidity is significantly reduced compared with the open approach.

Native nephrectomy in transplant patients with autosomal dominant polycystic kidney disease

INTRODUCTION

This study examined the clinical indications and timing for native nephrectomy (NN), together with the associated pathological findings in transplant patients with autosomal dominant polycystic kidney disease (ADPKD) at our institute over a period of 20 years.

METHODS

A retrospective review was performed of ADPKD patients who had undergone both kidney transplantation and NN. Patients were identified from the kidney transplant database between 1988 and 2008 at Guy's and St Thomas' Hospital and the notes reviewed. All NN specimens were re-reviewed and reported according to current guidelines.

RESULTS

There were 157 kidney transplants performed for ADPKD (114 cadaveric and 43 living donor). Of these, 31 required NN (28 bilateral). The timing of NN was pre-transplant in 10 cases, at the time of the transplant in 1 case and post-transplant in 20 cases. The indications for NN were urinary tract infection (n=14, 45%), pain (n=12, 39%), tumour suspicion (n=3, 10%), haematuria (n=1, 3%) and space (n=1, 3%). Mortality in this NN series was 3%, with a 65% surgical morbidity rate. The length of hospital stay post-NN was significantly longer with open compared with laparoscopic techniques (p=0.003). There were two renal cell carcinomas (RCCs) in this series. Both patients presented with macroscopic haematuria (bilateral pT1a papillary RCCs in one case and a pT3b clear cell RCC in the other case). The incidence of RCC in this series of ADPKD transplant patients was 1.3%.

CONCLUSIONS

We have demonstrated that the majority of ADPKD patients do not require NN, with only 20% of our series undergoing this procedure. The timing of NN is variable and dictated by indication. NN was only required to make space for transplantation in one case (combined kidney and pancreas transplant). The main indications for NN were recurrent infection and pain, where NN can provide a successful outcome. Laparoscopic NN can be performed safely in patients with ADPKD. Haematuria in such patients should not be assumed to be of benign origin and requires exclusion of urinary tract malignancy as the incidence of RCC in this population is at least as common as in the general population.

Giant polycystic kidney and acute abdomen in chronic renal failure

The case of a rare complication is reported of a 53-year-old patient with giant polycystic kidney (4250 g) that evolved with acute small bowel occlusion. The patient was submitted to surgery which identified that the intestinal occlusion was due to external compression of the intestinal loops. Excision of the mass solved the case.

Evaluation and management of pain in autosomal dominant polycystic kidney disease

Transient episodes of pain are common in autosomal dominant polycystic kidney disease (ADPKD). A small fraction of patients have disabling chronic pain. In this review, we discuss the etiologies of pain in ADPKD; review how ADPKD patients should be assessed; and discuss medical, surgical, and other management options.