Bilateral laparoscopic nephrectomy for significantly enlarged polycystic kidneys: a technique to optimize outcome in the largest of specimens

Robotic bilateral nephrectomy for large polycystic kidney disease

Objective

This study aims to describe our technique and review our experience with synchronous robotic bilateral nephrectomy for large kidneys in ADPKD with the da Vinci XI and da Vinci Single Port platforms (Intuitive Surgical, Sunnyvale, CA).

Materials and Methods

We performed a retrospective review of all robotic bilateral nephrectomy cases from January 2020 to present at a high-volume robotic single centre. Demographic data and perioperative details including preoperative CT scans, indication for nephrectomy and renal function were collected. We also collected post-op course data and final specimen data details.

Results

Fourteen cases were included. Patient demographics, indications for surgery and specimen data are outlined in Table 1. The largest kidney removed has a measurement of 32 cm in the largest dimension on preoperative imaging. Median operating time from incision to closure was 299 min (IQR 260, 339). Median estimated blood loss was 75 cc (IQR 50, 187.5). Two patients were transfused intraoperatively. Median pre- and post-operative Hgb was 11.0 and 9.6, respectively. Median length of stay was 3 days (IQR 2, 3.5). There were no intraoperative complications and no open conversions. Post-operative complications included one incisional hematoma and one superficial wound infection. One patient was admitted to the surgical ICU post operatively for ventilatory support. Two patients were readmitted within 30 days of surgery.

Conclusion

The robotic approach to bilateral native nephrectomy for ADPKD should be considered when native nephrectomies are indicated. The operative times and outcomes are favourable compared with prior series, and this technique works even for very large kidneys.

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.

Tolvaptan ameliorated kidney function for one elderly autosomal dominant polycystic kidney disease patient: A case report

BACKGROUND

Polycystic kidney disease (PKD) is a genetic disorder characterized by the growth of numerous cysts within the kidneys. Disease progress of some patients often occurs at the early stage. Thus, managing and controlling disease progress is important to slow the kidney function decline especially for the patient with other disorders.

CASE SUMMARY

One 80-year-old male autosomal dominant polycystic kidney disease (ADPKD) patient with chronic kidney disease and other clinical disorders was treated with tolvaptan and edoxaban. Estimated glomerular filtration rate, creatinine and uric acid were monitored during the treatment. In addition, the whole exome sequencing was performed to screen ADPKD genetic variants. The kidney function decline was prevented after using tolvaptan and edoxaban treatment and in the meantime, a venous thromboembolism was removed and leg and pedal edema were alleviated. One mutation c.10102G>A /p.D3368N in the PKD1 gene was identified.

CONCLUSION

Tolvaptan combined with edoxaban administration could delay kidney function decline and eliminate the edema caused by the thromboembolism.

Utilizing the same incision for staged renal transplant in patients with polycystic kidney disease requiring hand-assisted laparoscopic nephrectomy

BACKGROUNDS

Many autosomal dominant polycystic kidney disease (ADPKD) patients undergo nephrectomy and subsequent renal transplantation. We report our outcomes after hand-assisted laparoscopic nephrectomy (HALN) where a Rutherford-Morrison incision is used as a hand-port site and kidney extraction site, as well the future incision site for staged transplantation.

METHODS

A retrospective review was performed on all adult nephrectomies for ADPKD by the Transplant Surgery department at Westmead Hospital between June 2011 and June 2021. Outcomes were compared between HALN, laparoscopic nephrectomy (LN) and open nephrectomy (ON) including operation time, hospital length of stay (LOS), post-operative complications, subsequent transplantation and post-transplantation wound complications.

RESULTS

Twenty-two HALN, 8 LN and 5 ON were performed during the study period. Median kidney weights for HALN, LN and ON were significantly different (1575, 403, 3420 g respectively, P = 0.001). There was a significant difference in LOS between the HALN and ON (5.8 versus 9.8 days, P = 0.04), but not between HALN and LN (5.8 versus 5.1, P = 0.06). There was no significant difference for operation time (P = 0.34) and major complication rates (P = 0.58). There were 8 HALN, 5 LN and 2 ON who have had subsequent renal transplantation with one wound complication, an incisional hernia in the HALN group.

CONCLUSION

Our HALN is associated with a shorter LOS and similar complication rate to ON and can be efficiently performed for significantly larger kidneys than LN without a significant difference in operation time or LOS. The same Rutherford-Morrison incision site can be used for transplantation.

Safety and feasibility of synchronous unilateral nephrectomy and contralateral heminephrectomy for extremely severe autosomal dominant polycystic kidney disease: Techniques and outcome

PURPOSE

To demonstrate the safety and feasibility of synchronous unilateral nephrectomy and contralateral heminephrectomy in extremely severe autosomal dominant polycystic kidney disease (ADPKD), which corresponds to the Mayo imaging classification classes 1D and 1E.

MATERIALS AND METHODS

We retrospectively reviewed patients who underwent unilateral nephrectomy and contralateral heminephrectomy at the Seoul National University Hospital (Seoul, Korea) between May 1, 2016 and August 1, 2021. The preoperative kidney volume was calculated using the ellipsoid equation (length×width×thickness×π/6). The Mayo imaging classification was determined by height-adjusted total kidney volume and age. Using a midline vertical incision, heminephrectomy was performed first by horizontal transection, followed by contralateral nephrectomy. Hilar vessel clamping or resection-bed suturing was not required.

RESULTS

In all, nine patients with ADPKD of the highest severity (Mayo class 1D/1E) underwent unilateral heminephrectomy and contralateral nephrectomy for the most common cause of severe abdominal discomfort and malnutrition. All nine patients had end-stage renal disease with hypertension and anemia. The median preoperative total kidney volume was 10,905.8 mL (interquartile range [IQR], 8,170.4-16,227.6 mL). The median operation time was 140 minutes (IQR, 125-185 min) and the median estimated blood loss was 250 mL (IQR, 200-425 mL). Eight of the nine patients were discharged without ICU care or any complications. Delayed pseudoaneurysm occurred in one case and was successfully managed by embolization. All patients were symptom-free for a median follow-up period of 2 years.

CONCLUSIONS

Synchronous unilateral nephrectomy and contralateral heminephrectomy are safe and feasible treatment options for severe bilateral ADPKD.

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.

Bilateral Nephrectomy in Patients with Autosomal Dominant Polycystic Kidney Disease and End-Stage Chronic Renal Failure

BACKGROUND

In patients with autosomal dominant polycystic kidney disease (ADPKD) and end-stage kidney disease, bilateral nephrectomy (BN) is currently performed predominantly via the laparoscopic approach. We analysed the results of BN depending on the approach and preoperative and perioperative factors.

PATIENTS AND METHODS

This was a single-centre retrospective study carried out from April 2010 to March 2020, including a total of 142 patients presenting with ADPKD who were treated by BN. Of these, 108 patients meeting the inclusion criteria were selected to analyse the results. We compared therapeutic outcomes depending on the surgical approach (laparotomy or laparoscopy) and the type of the operation (emergent or elective).

RESULTS

Of the 108 eligible patients, 36 (group I) underwent laparoscopic BN and the remaining 72 patients (group II) were subjected to midline laparotomy. Sixty-nine patients underwent elective surgery and 39 endured emergent operations. The most frequent indications (87 patients, 80.6%) for surgical treatment were urinary tract infection and infected cysts. The median length of hospital stay for group I and group II patients amounted to 8 days (IQR: 7.5-9) and 12.5 days (IQR: 9-16.5), respectively (p < 0.001). However, comparing the patients operated on electively, the actual difference in the length of hospital stay was inconsiderable: median 8 days (IQR: 7-9) in group I and 9 days (IQR: 9-11.5) in group II. The median duration of the operation was significantly (p < 0.001) longer in group I amounting to 217.5 min (IQR: 197.5-305) than in group II equalling 115 min (IQR: 107.5-145). The frequency of postoperative complications, lethal outcomes, and blood loss volume did not statistically significantly differ depending on the surgical approach. Only patients operated on emergency underwent releparotomy due to intraoperative large bowel injury. Lethal outcomes (n = 18, 16.7%) after surgery were observed only in emergent patients. Sepsis prior to surgery, systemic inflammation response syndrome (SIRS) with the CRP level above 173 mg/mL, prolonged preoperative antibacterial therapy, and undiagnosed large bowel injury were associated with a lethal outcome after BN.

CONCLUSION

The results of open and laparoscopic BN in elective surgery were comparable. Emergency operations for infected renal cysts and SIRS were associated with increased incidence of large bowel injury and lethal outcomes.

Simultaneous Hand-assisted Laparoscopic Bilateral Native Nephrectomy and Kidney Transplantation for Patients With Large Polycystic Kidneys

OBJECTIVE

To describe our technique of simultaneous hand-assisted laparoscopic bilateral native nephrectomy (BNN) and kidney transplantation (KT) in patients with autosomal dominant polycystic kidney disease and present our experience.

MATERIALS AND METHODS

We retrospectively reviewed a cohort of adult ESRD patients with symptomatic autosomal dominant polycystic kidney disease who underwent a hand-assisted laparoscopic BNN at the time of KT. We reviewed patients' and donor characteristics, and perioperative and postoperative outcomes.

RESULTS

A total of 52 patients underwent hand-assisted laparoscopic BNN at the time of KT from January 2014 to October 2019. The median age of the recipients was 53.4 years, 57.7% were males, and the median body mass index was 29.0 kg/m². All but one received a kidney from a living donor and the majority (86.5%) were pre-emptive. One patient required a small bowel resection due to an intraoperative small bowel injury. There was no solid organ injury during the procedure. All patients showed immediate allograft function and a steady decline in serum creatinine. The median decline in the creatinine and hemoglobin on day 1 was 1.2 mg/dL (inter quartile range 0.6-2.3) and 2.2 g/dL (inter quartile range 1.4-3.0), respectively.

CONCLUSION

Simultaneous hand-assisted laparoscopic bilateral nephrectomy with KT through a modified Gibson incision is feasible and safe in the hands of an experienced laparoscopic surgeon without compromising allograft function.

Robot-assisted Synchronous Bilateral Nephrectomy for Autosomal Dominant Polycystic Kidney Disease: A Stepwise Description of Technique

OBJECTIVE

To describe our technique of robot-assisted synchronous bilateral nephrectomy (RASBN) for autosomal dominant polycystic kidney disease (ADPKD).

METHODS

Given prior abdominal surgery/transplant in most patients, we prefer an open cut-down access to place a 12 mm port 10 cm infraumbilically. Four (8 mm) robotic ports are then placed under vision in a fan distribution along the umbilical level. The operating table is placed in reverse Trendelenburg and tilted opposite to the targeted side. Provided there are no concerns for malignancy, some cysts encountered in large kidneys (>2.5 L) may require puncture, to facilitate access and mobilization. The resected kidney is placed in a large bag and tucked in the pelvis. A similar procedure is carried out on the contralateral side after redocking the robot and tilting the table in the opposite direction. The specimen bags are extracted by elongating the lower midline 12 mm port site.

RESULTS

Seven cases of RASBN performed for ADPKD were identified (December 2015 to December 2018). Median (interquartile range, IQR) values for patient demographics were: Age = 59 years (47-63), body mass index = 29 (26-32), and American Society of Anaesthesiology grade = 3. Three patients had prior deceased- and 4 had prior living- donor transplants. Indication for nephrectomy were: pain (5), hemorrhage into cysts (3), and renal masses (2). Perioperative outcomes were: operating room time = 388 minutes, estimated blood loss = 200 mL, hemoglobin change = 1.3 g/dL, transfusion = 0, length of hospital stay = 3 days, Grade I Clavien-Dindo complications = 2 cases. All patients were alive at a median follow-up of 3.8 years.

CONCLUSION

RASBN is safe and effective in ADPKD even in the context of prior renal transplant patients with attendant comorbidities.

Technical Challenges and Innovations in Kidney Transplantation: Experience With Over 5000 Cases

Kidney transplant has been the standard-of-care treatment for patients with end-stage renal disease for many years. To expand the acceptance and care of complicated situations in patients with end-stage renal disease, transplant teams should be ready to find innovative solutions to prevent and manage pretransplant, intraoperative, and posttransplant problems. In this report, we present our approach for the following scenarios: transplant in patients with urinary diversion and augmentation, polycystic disease in recipients, tumors in transplanted kidney and native kidneys, and the roles of laparoscopy and mini-laparoscopy in kidney transplant.

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.

Laparoendoscopic Single-Site Surgery for Pediatric Urologic Disease

BACKGROUND

Laparoendoscopic single-site surgery (LESS) was performed for 31 cases of pediatric urologic disease in our department.

OBJECTIVE

A retrospective chart review was performed on pediatric patients who underwent LESS.

DESIGN, SETTING, AND PARTICIPANTS

Procedures included pyeloplasty (21), nephrectomy (4), varicocele ligation (3), orchiectomy (1), orchiopexy (1), and removal of female genitalia (1). In all 31 cases, an incision of 15 to 20 mm was made in the umbilical region, and a port for LESS was put in place. A 5-mm flexible scope and 5-mm forceps with a bending tip and regular laparoscopic forceps (3, 5 mm) were used.

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

Intraoperative and postoperative outcomes were evaluated.

RESULTS AND LIMITATIONS

For the 21 patients with pyeloplasty, the mean operation time was 240 minutes. Postoperative renal pelvis dilatation was relieved in all patients. For the 4 patients with nephrectomy, the mean operation time was 128 minutes. Postoperative urinary incontinence disappeared in all patients. The mean operation time of varicocele ligation was 73 minutes. Postoperation, varicocele disappeared and there was no testicular atrophy. The operation times of orchidectomy, bilateral orchidopexy, and removal of female genitalia mutilation were 60, 170, and 189 minutes, respectively. In all cases, there were no intraoperative or postoperative complications.

CONCLUSIONS

The advantages of LESS include superior aesthetics with a smaller scar and less pain. LESS is considered as a less burdensome surgery for pediatric patients.

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.

A stepwise approach for effective management of chronic pain in autosomal-dominant polycystic kidney disease

Chronic pain, defined as pain existing for >4-6 weeks, affects >60% of patients with autosomal-dominant polycystic disease (ADPKD). It can have various causes, indirectly or directly related to the increase in kidney and liver volume in these patients. Chronic pain in ADPKD patients is often severe, impacting physical activity and social relationships, and frequently difficult to manage. This review provides an overview of pathophysiological mechanisms that can lead to pain and discusses the sensory innervation of the kidneys and the upper abdominal organs, including the liver. In addition, the results of a systematic literature search of ADPKD-specific treatment options are presented. Based on pathophysiological knowledge and evidence derived from the literature an argumentative stepwise approach for effective management of chronic pain in ADPKD is proposed.

Laparoscopic nephrectomy for adult polycystic kidney disease: safety, feasibility, and early outcomes

BACKGROUND AND PURPOSE

Indications for laparoscopic renal surgery are increasing; however, benefits in adult polycystic kidney disease (APKD) remain uncertain. Our objective was to systematically synthesize the reported literature on safety, feasibility, complications, and early outcomes of laparoscopic nephrectomy in APKD to determine clinical benefits for surgical practice.

METHODS

We conducted a meta-analysis of the published literature reporting on laparoscopic nephrectomy in APKD between 1991 and 2013. The criteria from the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) study were used to assess the quality of reported literature.

RESULTS

One prospective and 15 retrospective studies of low to modest quality (according to the STROBE checklist) were identified, reporting on 293 patients who underwent laparoscopic nephrectomy for APKD. None of the studies was a randomized clinical trial (RCT). The transperitoneal approach was the most commonly used technique. Body mass index ranged from 16 to 57 (mean 26.2 kg/m(2); 53% of patients were dialysis dependent, and 31% had a previous or simultaneous transplant. Kidney length ranged from 8 to 50 cm (mean 34.5cm), and the mean mass of affected kidneys was 1647 g (range 132 g-7200 g). Duration of hospital stay ranged from 2.6 to 11 days (mean 4.9 days). Operative time ranged from 90 to 568 minutes, with 16.2% of patients needing blood transfusion. There were 24 intraoperative complications and 68 postoperative complications, a rate of 8% and 24%, respectively. A total of 16 (5%) cases were converted to an open technique. No mortality was reported in any of the included studies.

CONCLUSION

The quality of the included studies is poor, and it is difficult to argue for or against change in clinical practice because the evidence included is of level 3 and 4 only. Higher quality studies are needed to demonstrate that the technique is generalizable across all populations.

Trends in the management and outcomes of kidney transplantation for autosomal dominant polycystic kidney disease

Background. Autosomal dominant polycystic kidney disease (ADPKD) is the most common genetic disorder leading to end-stage renal failure. The objective of this study was to evaluate a longitudinal experience of kidney transplantation for ADPKD. Methods. A single center retrospective review of patients undergoing kidney transplantation was conducted, with comparisons across two time periods: early (02/2000–04/2007, n = 66) and late (04/2007–08/2012, n = 67). Results. Over the 13.5-year study period, 133 patients underwent transplantation for ADPKD. Overall, no significant difference between the early and late group with regard to intraoperative complications, need for reoperation, readmissions within 30 days, delayed graft function, and mortality was noted. There was a trend towards increase in one-year graft survival (early 93.1% versus late 100%, P = 0.05). In the early group, 67% of recipients had undergone aneurysm screening, compared to 91% of recipients in the late group (P < 0.001). Conclusions. This study demonstrates consistent clinical care with a trend towards improved rates of one-year graft survival. Interestingly, we also note a significantly higher use of cerebral imaging over time, with the majority that were detected requiring surgical intervention which may justify the current practice of nonselective radiological screening until improved screening criteria are developed.

[Laparoscopic nephrectomy for polycystic kidneys: principles and results]

OBJECTIVE

To evaluate the feasibility and morbidity of laparoscopic nephrectomy in patients with autosomal dominant polycystic kidney disease (ADPK).

PATIENTS AND METHOD

This is a retrospective multi-centre study (University Hospitals of Lyons, Toulouse, Nantes and Rennes). Sixty-eight patients who had undergone laparoscopic nephrectomy for polycystic kidney disease between November 1999 and May 2009 were included. This involved unilateral nephrectomy 64 cases, one-stage bilateral in one case and two-stage bilateral in three cases.

RESULTS

The mean operating time was 218±74min (100-420) Conversion was necessary in 7 cases. The mean weight of the removed kidney was 1291±646g (240-3400). We regret to report 20 postoperative complications, including one death on postoperative day 50, following an abscess in the renal pelvis, 6 retroperitoneal haemoatomas and 5 arteriovenous fistula thromboses. Postoperative analgesia involved PCA treatment with morphine for a mean period of 1.59±0.8 days (0.5-4). The mean length of hospital stay was 8.3±6.1 days (3-50).

CONCLUSION

This study shows the feasibility of the laparoscopic approach for nephrectomy in ADPK. This procedure should be performed by experienced laparoscopic surgeons. Indeed, the complication rate is moderate but there is still a risk of severe complications.

LEVEL OF EVIDENCE

5.

Renal transplantation and polycystic: surgical considerations

BACKGROUND

The indication and timing of nephrectomy in patients with autosomal dominant polycystic kidney disease (ADPKD) remain controversial, especially in patients who are candidates to renal transplantation (RT). The main surgical options such as unilateral vs. bilateral nephrectomy, nephrectomy before vs. after RT, or simultaneous nephrectomy and transplantation, are herein discussed.

OBJECTIVE

Evidence acquisition of the best surgical management available for ADPKD in the context of kidney transplantation.

ACQUISITION OF EVIDENCE

Systematic literature review in PubMed from 1978 to 2013 was conducted. Articles selected included:randomized controlled trials and cohort studies. Furthermore, well designed ADPKD reviews were considered for this study.

SYNTHESIS OF EVIDENCE

Laparoscopic nephrectomy in ADPKD is a safe procedure with an acceptable complication rate. Unilateral nephrectomy has advantages over the bilateral one regarding the perioperative complication rate. Although the timing of nephrectomy is controversial, it seems that simultaneous nephrectomy and renal transplantation does not increase surgical morbidity neither affect graft survival.

CONCLUSIONS

Simultaneous nephrectomy and RT appears to be an acceptable alternative to conventional two-stage procedure without any increased morbidity, in the context of ADPKD. Furthermore, laparoscopic nephrectomy performed in experienced centres is a safe alternative to conventional approach.

Hand-assisted laparoscopic nephrectomy for polycystic kidney disease

BACKGROUND AND OBJECTIVES

Historically, nephrectomy for autosomal dominant polycystic kidney disease was performed by an open technique. We performed this study to compare outcomes in hand-assisted laparoscopic nephrectomy with open nephrectomy in this population.

METHODS

Charts of patients with autosomal dominant polycystic kidney disease who underwent nephrectomy by a transplant surgeon from January 1, 2000, to December 31, 2011, were reviewed. The hand-assisted laparoscopic nephrectomy group was compared with the open group. Data collected included unilateral versus bilateral nephrectomy, operative time, complications, transfusion requirement, and length of stay.

RESULTS

Of the 78 patients identified, 18 underwent open transabdominal nephrectomy, 56 underwent hand-assisted laparoscopic nephrectomy, and 2 underwent hand-assisted laparoscopic nephrectomy that was converted to an open procedure. Two patients were excluded because another major procedure was performed at the same time as the nephrectomy. Operative times were similar. Patients undergoing open bilateral nephrectomy were more likely to receive transfusion (odds ratio, 3.57 [95% confidence interval, 0.74-17.19]; P = .016), and the length of stay was longer in the open groups (5.9 days vs 4.0 days for unilateral [P = .013] and 7.8 days vs 4.6 days for bilateral [P = .001]). Overall complication rates were similar. The most frequent complications associated with hand-assisted laparoscopic nephrectomy were the development of an incisional hernia at the hand-port site and arteriovenous fistula thrombosis.

CONCLUSION

Hand-assisted laparoscopic nephrectomy can be safely performed without increased operative times or complications. The hand-assisted laparoscopic nephrectomy group enjoyed a shorter length of stay, and fewer patients in this group received transfusion. For patients considering renal transplantation, avoidance of transfusion is important to prevent sensitization and limiting access to compatible organs.

Laparoscopic bilateral native nephrectomies with simultaneous kidney transplantation

Study Type--Therapy (case series) Level of Evidence 4. What's known on the subject? and What does the study add? Extirpation of polycystic kidneys for various medical reasons has been performed using many different approaches in attempts to limit morbidity from such a large operation. In indicated patients, it has usually been offered in a staged approach with renal transplantation to avoid graft complications. We published the first case of simultaneous laparoscopic bilateral native nephrectomy with kidney transplant in 2008. The present study shows our continued experience with offering this minimally invasive, single surgery alternative. The results are comparable to a staged laparoscopic approach with significantly shorter total hospital stay and one recovery for the patient and his/her family.

OBJECTIVE

• To analyse the perioperative outcomes of native bilateral laparoscopic nephrectomy (BLN) with simultaneous kidney transplantation.

PATIENTS AND METHODS

• From November 2000 to April 2011, 37 patients were seen for renal failure secondary to autosomal-dominant polycystic kidney disease (ADPKD) and underwent renal transplant with native nephrectomies at a single tertiary academic centre. • In all, 15 patients underwent BLN for ADPKD followed by simultaneous kidney transplantation. • The other 22 patients underwent BLN for ADPKD with kidney transplant performed at a separate setting. • Demographic data, perioperative outcomes, complications regardless of need for intervention, and graft function were analysed in both groups.

RESULTS

• The combined surgery was completed without intraoperative complication in all cases. • The median total operative duration was 372 min, estimated blood loss was 300 mL with two patients requiring transfusion, and the median (range) hospital stay was 5 (3-7) days. • All patients had immediate graft function with additional relief of compressive symptoms. • In comparison to our staged cohort, the simultaneous group had a significantly shorter total hospital stay. • All other outcomes and complication rates were comparable.

CONCLUSION

• In ADPKD, a less invasive laparoscopic approach for native nephrectomies with simultaneous renal transplant offers comparable morbidity without graft compromise and the convenience of one operation and one recovery for the patient.

[The laparoscopic left-sided renal tumor enucleation with synchronous cyst removal in the right kidney without changing port positions]

Bilateral synchronous kidney alterations which need to be treated surgically are rare. Nevertheless, they are known and present a difficult situation with respect to the access and type of operation. Conventional open surgery (laparotomy, bilateral flank incisions) is always combined with severe tissue trauma, whereas minimally invasive techniques are often chosen for patients with little previous surgery and less complicated pathology. It is believed that especially for synchronous bilateral kidney surgery, laparoscopy is a very good option even if patients have had extensive previous surgery.

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.

Simultaneous bilateral single-port radical nephrectomies

The management of bilateral enhancing renal masses can be technically challenging. Simultaneous bilateral laparoscopic nephrectomies in postrenal transplant patients have been previously described, but these typically require multiple port placements in addition to a hand port. Herein, we describe simultaneous bilateral single-port laparoscopic radical nephrectomies in a postrenal transplant patient.

Single-session laparoscopic total urinary tract exenteration without repositioning for multifocal urothelial carcinoma in dialysis-dependent patients

OBJECTIVES

To report our experience of single-session, en bloc, laparoscopic total urinary tract exenteration in dialysis-dependent patients with multifocal urothelial carcinoma.

METHODS

From June 2005 to April 2008, 5 dialysis-dependent patients (4 women and 1 man) diagnosed with synchronous upper urinary tract and bladder urothelial carcinoma underwent single-session, en bloc, laparoscopic total urinary tract exenteration. Bilateral nephroureterectomy was facilitated by rotating the operating table with or without alternative inflation of the tourniquet cuffs on either side of the patient's back to allow adequate spontaneous bowel displacement by gravity, thereby avoiding the need to reposition the patient. After completing bilateral nephroureterectomy, we performed radical cystectomy with the patient in the Trendelenburg position. All specimens, including the 2 kidneys, ureters, and bladder, were collected in an endobag and were intended to be retrieved using the Pfannenstiel incision in male patients and the vaginal route in the female patients. The demographic and perioperative information were collected and analyzed.

RESULTS

All the laparoscopic procedures were completed successfully without major complications. Although 1 patient developed a minor complication owing to paralytic ileus, she recovered after conservative treatment. The continuity of all the urothelial epithelium was maintained intact throughout the procedure to avoid tumor spillage.

CONCLUSIONS

In our experience, laparoscopic total urinary tract exenteration is a technically feasible and safe alternative modality to the open counterpart to treat dialysis-dependent patients with end-stage renal disease with multifocal urothelial carcinoma for experienced surgeons with advanced laparoscopic skills. Furthermore, it can be performed successfully without the need for repositioning the patient, and this probably decreased the incidence of associated complication in the high-risk patients.

Outcome of hand assisted laparoscopic bilateral native nephrectomy in transplant recipients

PURPOSE

We explored the safety and reproducibility of hand assisted laparoscopic bilateral native nephrectomy. We also present our improvements to the surgical technique.

MATERIALS AND METHODS

We retrospectively reviewed the charts of 36 patients who underwent hand assisted laparoscopic bilateral nephrectomy at our institution between 2003 and 2010. In all cases the 2 kidneys were removed transperitoneally via a hand assisted laparoscopic technique.

RESULTS

Mean operative time was 222 minutes. Pathological kidney size was 20 to 34 cm. Mean hospital stay was 3 days (range 1 to 13). Average estimated blood loss was 175 cc (range 50 to 200). No patient required intraoperative blood transfusion. There were no intraoperative complications and no conversions to open surgery. Postoperatively complications developed in 8 patients (22%), including temporary adrenal insufficiency and pulmonary embolism in 1 each, and myocardial infarction, superficial wound infection and loss of arteriovenous fistula function in 2 each. According to the Clavien-Dindo classification complications were grades 1, 2, 3 and 4a in 2, 3, 1 and 2 patients, respectively. A total of 18 patients with kidney transplants continued to have normal graft function after surgery.

CONCLUSIONS

Simultaneous hand assisted bilateral nephrectomies are safe and reproducible. The complication rate is low and postoperative hospital stay is short compared to those in published open surgery series. Graft function was preserved in patients who underwent renal transplantation before native kidney removal.

Hyperbaric oxygen therapy in a patient with autosomal dominant polycystic kidney disease with a perinephritic abscess

A 68-year-old female in hemodialysis due to autosomal dominant polycystic kidney disease underwent resection of cysts in her right kidney via a laparoscopic approach due to abdominal pain. Three weeks after surgery, she was admitted with sepsis. A CT scan showed a large abscess around the right kidney. Percutaneous drainage of abscess was performed. The pus smear showed Gram-positive cocci and the culture contained methicillin-resistant Staphylococcus aureus. Ciprofloxacin, clindamycin and vancomycin were given. In the 3 weeks following admission, she remained febrile and septic and showed a progressive deterioration in her general condition, along with malnutrition and persistent drainage of purulent material from her right flank. The antibiotic therapy was changed to vancomycin, metronidazole and meropenem, but no improvement was observed. Because of the high risk associated with carrying out an open nephrectomy, we decided to use hyperbaric oxygen therapy (HBOT) as a potentially useful measure to control her infection. The patient underwent 26 daily sessions of 100% hyperbaric oxygen (2.5 atm). The use of HBOT induced a notable break in the clinical course of this patient's retroperitoneal infection. She was discharged after day 58 without any signs of inflammatory activity, and she has not presented reactivation of infection since then. We think that this case suggests that this therapy could be a new therapeutic tool in the management of patients with similar clinical features when all other therapeutic measures have failed. We did not find any other reports of the use of HBOT in infections of renal cysts.

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.

Autosomal dominant polycystic kidney disease: the last 3 years

Autosomal dominant polycystic kidney disease is the most prevalent, potentially lethal monogenic disorder. It has large inter- and intra-familial variability explained to a large extent by its genetic heterogeneity and modifier genes. An increased understanding of its underlying genetic, molecular, and cellular mechanisms and a better appreciation of its progression and systemic manifestations have laid out the foundation for the development of clinical trials and potentially effective therapies. The purpose of this review is to update the core of knowledge in this area with recent publications that have appeared during 2006-2009.

Single-incision laparoscopic surgery: initial urological experience and comparison with natural-orifice transluminal endoscopic surgery

Laparoscopic approaches have increasingly assumed a central role in the management of benign and malignant surgical diseases. While laparoscopy is less morbid than open surgery, it still requires several incisions, each > or =1-2 cm long. Each incision risks morbidity from bleeding, hernia and/or internal organ damage, and incrementally decreases cosmesis. An alternative to conventional laparoscopy is single-incision laparoscopic surgery (SILS), in which articulating or bent instrumentation with specialized multi-lumen ports is used. These technical innovations obviate the need to externally space trocars for triangulation, thus allowing the creation of a small, solitary portal of entry into the abdomen. Laboratory and early clinical series showed the feasibility as well as safe and successful completion of SILS. Natural-orifice transluminal endoscopic surgery (NOTES) is another exciting development in minimally invasive urology, but existing flexible endoscopes and instruments are limited in providing a platform for this form of advanced surgery, resulting in the slow adoption of NOTES. Future work is needed to improve existing instrumentation, increase clinical experience, assess the benefits of both surgical approaches, and explore other potential applications for these novel techniques.