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Laparoscopic management of renal cystic disease
ADVANCEDUROLOGICLAPAROSCOPY
0094-0143/01 $15.00 + .00
LAPAROSCOPIC M A N A G E M E N T OF RENAL CYSTIC DISEASE A s h o k K. H e m a l , MS, MCh, FACS
Renal cystic disease is a common incidental, radiographic, and postmortem finding. It is estimated that evidence of renal cysts exists in 50% of the adult population. 25 The increased use of imaging modalities such as ultrasonography and CT has produced a corresponding increase in the detection of renal cystic disease. Simple renal cysts occur with an incidence of at least 20% by age 40 years and 33% at age 60 years. 26 Most of these lesions are asymptomatic. At times, the lesions may be associated with dull renal angle pain, flank pain, hypertension, a palpable mass, hematuria, infection, and collecting system obstruction 19,33 Symptomatic renal cysts can be treated by percutaneous aspiration with or without injection of sclerosants, 9 percutaneous marsupializationy open surgery, 1 and, most recently, by laparoscopic surgery b y transperitoneal and retroperitoneal access. 9,14,33 Peripelvic cysts are rare forms of renal cysts that are more commonly associated with pain, obstruction, infection, and stone formation. 16 Owing to their proximity to the renal hilum, these cysts offer a challenge in management. Percutaneous aspiration and instillation of sclerosants is difficult because of the risk for injury to nearby vessels. Ureteronephroscopic23and percutaneous marsupialization 2°,23 have been described; however, such cysts have most commonly been treated by open surgery, i, 16 except recently b y laparo-
scopic ablation, both transperitoneally and retroperitoneally.14,16 Certain renal cysts can be associated with other pathologic conditions, such as autosoreal dominant polycystic kidney disease (ADPKD) and acquired cystic disease in chronic dialysis. 21 ADPKD is an important cause of renal failure accounting for approximately 9% to 10% of patients on chronic hemodialysis. Other clinical manifestations include hypertension, chronic pain, hematuria, urinary tract infection, stone formation, and cyst infection. The traditional management of these cases has included narcotic analgesics, antibiotics, needle aspiration of d o m i n a n t cysts, and open renal cyst decortication77, 32 Laparoscopic cyst decortication is another option with similar efficacy to open surgery and less morbidity. 6, is, 27
EVALUATION Renal cystic disease can be adequately evaluated with ultrasonographic techniques. 38 For more complicated lesions, renal CT is the cornerstone of diagnosis. Based on CT scan, renal cysts have been classified into four categories by Bosniak# Type I--This simple cyst is the most common and generally requires no treatment, although, rarely, a large simple cyst
From the Department of Urology, All India Institute of Medical Sciences, N e w Delhi, India
UROLOGIC CLINICS OF NORTH AMERICA VOLUME 28 • NUMBER 1 • FEBRUARY 2001
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causes symptoms or obstruction and requires intervention. Type II--This h o m o g e n o u s h y p e r d e n s e cyst has thin septations and fine calcification that do not enhance after intravenous injection of contrast medium. Type III--This multiloculated cystic mass or cyst has thick irregular calcifications, a thick wall, or nodularity. Type IV--A cyst associated with a solid component; such lesions are considered to be cystic malignancies and should be managed with radical nephrectomy. Magnetic resonance imaging can be used in patients with contrast allergy, an elevated serum creatinine level, or a hyperdense renal cyst. MR imaging also helps in evaluation of the cyst wall. The role of intravenous urography is limited; it depicts cystic diseases as space-occupying lesions or demonstrates compression. Ultrasound is the recommended imaging modality for reliable identification and follow-up of cystic lesions. Equivocal cysts raising the possibility of malignancy can be further evaluated with CT, but, if any doubts remain regarding the nature of the lesion, percutaneous aspiration or biopsy is advocated to provide a definitive answer. The sensitivity for the detection of malignancy using percutaneous techniques is 90%. The specificity for the determination of benign disease is 92%. 3s
INDICATIONS Depending on the symptoms, size, site, locations, number, presence of infection, suspicion of malignancy, and other associated pathologic conditions, the following renal cystic disorders can be managed by laparoscopic intervention: 1. Bosniak type I and II renal cysts--large symptomatic renal cysts (-> 10 cm in size) directly taken up for laparoscopic management; smaller symptomatic renal cysts treated by percutaneous aspiration alone or with a sclerosing agent, failing which laparoscopic resection can be undertaken 14 2. Indeterminate cystic masses evaluated laparoscopically and m a n a g e d according]y34 3. Renal cystic masses with malignancy-treated by laparoscopic radical nephrectomy 1°
Table 1. OPERATIVE STEPS FOR RETROPERITONEOSCOPIC RENAL CYST MANAGEMENT
I. II. III. IV. V. VI. VII. VIII. IX. X. XI.
Position of patient Creation of retroperitoneal space Secondary port placement Kidney identification Identification and dissection of the cyst Aspiration and further dissection Excision/near-total resection/marsupialization/ deroofing Hemostasis/fulguration of cyst edge and wall Tacking of perirenal fat/polytetrafluoroethylene wick Drain placement (optional) Exiting the retroperitoneum
4. Peripelvic or parapelvic cysts 16 5. ADPKD 6 6. Renal hydatid cysts Laparoscopic evaluation, marsupialization, excision, and radical nephrectomy for a cystic mass harboring malignancy offer a definitive treatment for patients who have renal cystic diseases and can obviate open surgery.
LAPAROSCOPIC TECHNIQUES OF MANAGEMENT The laparoscopic approach is far less invasive than open surgery for an appropriate case of renal cystic disease. The approach may be retroperitoneoscopic or transperitoneal. The operative steps of these accesses are described in Tables 1 and 2.
Retroperitoneoscopic Technique The patient is placed in the standard flank position, the kidney bridge is elevated, and
Table 2. OPERATIVE STEPS FOR LAPAROSCOPIC RENAL CYST EXCISION OR DECORTICATION BY TRANSPERITONEAL ROUTE
I. II. III. IV. V. VI. VII. VIII. IX. X. XI.
Position of patient Pneumoperitoneum/primary port placement Secondary port placement Incision of the line of Toldt Identification of kidney/opening Gerota's fascia Identification and dissection of the cyst Aspiration and further dissection Excision/cyst decorticafion or deroofing Hemostasis / fulguration Tacking of perirenal fat Exiting the abdomen
LAPAROSCOPIC MANAGEMENT OF RENAL CYSTIC DISEASE
the operating table is flexed to maximize the space between the lowermost rib and the iliac crest. A 1.5- to 2-cm incision is made an inch below and posterior to the tip of the 12th rib for the primary port. The incision is deepened down to the thoracolumbar fascia and further developed posteriorly and toward both poles using a Clutton's dilator or digital dissection. Subsequently, a home-made balloon created by tying two finger stalks of a size 7.5 latex glove one inside the other over a catheter is inserted in the space created. The balloon is inflated with 300 to 400 mL of saline for 5 minutes to create adequate space in the retroperitoneum and secure hemostasis. If feasible, especially in a thin patient, the balloon is placed underneath Gerota's fascia. The custom-made balloon is used to reduce the cost; otherwise, the surgeon can use a trocarmounted dilator balloon device (Origin Medsystems, Menlo Park, CA) for creating a working space in the retroperitoneum. The balloon is removed, and a 10-ram blunt tip trocar (Origin Medsystems) is placed as the primary port. The trocar's balloon seals the incision, preventing leakage of gas. To reduce the cost, the author uses a reusable cannula as a primary port. The cannula is stabilized with two preplaced sutures of 1 / 0 nylon through the parietal musculature and thoracolumbar fascia, preventing the extravasation of carbon dioxide (CO2), leading to subcutaneous emphysema and preventing leakage b y the side of the port. The author prefers to place the secondary ports under laparoendovision. The second port may be placed parallel to the primary port in the posterior axillary line, at least 3 cm above the iliac crest to allow maneuverability. The third port can be placed in the midaxillary line according to the location of the cyst at the lower or upper pole. In most cases, surgery can be performed with three ports. A fourth port is optional. In the three-port technique, it is necessary to have two ports of 10 to 11 mm in size. The surgeon should be careful to avoid transgression of peritoneum during secondary port placement. The advantages of the retroperitoneoscopic technique are as follows: 1. It offers direct access to the retroperitoneally located genitourinary organs with no need for peritoneal entry or colonic mobilization. 2. The potential for intraperitoneal organ (visceral and vascular) injury is minimized.
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3. The possibility of spillage of renal cystic fluid into the peritoneal cavity is eliminated, and postoperative hematoma or urinoma is confined to the retroperitoneum. 4. The risk for future adhesive obstruction and hernia is decreased. 5. The route can be used in patients who have undergone transperitoneal abdominal operations.
Disadvantages The relatively small working space in the retroperitoneoscopic approach may cause difficulty in mobilizing a large kidney, such as in ADPKD, for complete deroofing of the cyst. Sometimes, anteromedially located renal cysts and peripelvic cysts m a y create difficulty while attempting to excise the cysts completely.
Renal Cysts If the retroperitoneal space is created underneath Gerota's fascia, the kidney lies directly in front; otherwise, the overlying fascia of Gerota is usually thinned out, and the bluedomed cysts are easily recognized. Gerota's fascia is divided in relation to the location of the cyst. If the cyst is located anteriorly, medially, or anteromedially, the kidney is mobilized on the lateral border and retracted posteriorly with the help of a triflanged retractor to delineate the anterior surface of kidney. When doubt remains concerning the nature of the cyst, u n d e r laparoendovision, percutaneous puncture of the cyst is undertaken and the fluid sent for analysis and cytologic examination. The location of the cyst can also be confirmed with the help of laparoscopic ultrasound. A totally intrarenal cyst is a contraindication to a primary laparoscopic approach. The basic steps for the various types of renal cysts (Figs. 1-4) are the same; however, the clinician should be aware of anatomy preoperatively. A combination of blunt and sharp dissection using a dissector and scissor permits rapid and complete mobilization of the cyst surface. When the cyst is very tense, after initial exposure, it can be p u n c t u r e d and grasped with the help of an atraumatic dissector that provides countertraction for further dissection. The renal cyst can be further treated in the following ways.
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, The renal cyst can be completely excised when a good plane of cleavage can be developed between the cyst and the underlying parenchyma (see Fig. 3), • If the previous maneuver is not possible, near-total excision of the cyst wall is performed to avoid damage to the underlying collecting system or renal p a r e m chyma, tn these cases, the edges and base of the residual cyst wall are fulgurated. The surgeon should be extremely cautious while fulgurating the base because it overlies renal parenchyma and is in
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close proximity to the pelvicaliceal system. • The renal cyst can be marsupialized by excising the wall To decrease the possibility of recurrence, sub~ sequent to excision or marsupialization, peri~ nephric fat is tacked into the cavity,
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LAPAROSCOPICMANAGEMENTOF RENALCYSTICDISEASE
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Figure 4. A, Ultrasound shows a large left peripelvic renal cyst, B, Intravenous urography demonstrates left peripelvic cyst, a space occupying lesion with obstruction to lower calyx. C, CT scan of abdomen reveals left peripelvic cyst,
dissection in patients with peripelvic cysts (Fig. 4). The presence of a ureteral catheter is of great help in identifying the compressed and distorted collecting system. The splayed out renal vessels are identified by careful dissection alone. If available, the clinician can employ a laparoultrasound probe to identify these vessels. Because the cysts are deeply ensconced in the renal sinus, aggressive resection of the cyst wall should not be attempted; instead, incomplete excision of cyst wall or marsupialization must be performed. To prevent recurrence, a pedicle of perirenal fat is placed in the cavity. At the end of the procedure, sterile methylene blue is injected through the preplaced ureteral catheter to identify any leak from the pelvicaliceal system.
Renal Hydatid Cyst After exposing the cyst, the retroperitoneal space is filled with normal saline and the
cyst punctured under laparoendovision. The contents are aspirated out, and the cavity is refilled with dilute povidone-iodine solution and drained, washing it out completely. At this stage, the cyst is excised in the same manner as renal cysts, and the perirenal fat is tacked in the space created. Once again, the retroperitoneal space is washed with normal saline.
Autosomal Dominant Polycystic Kidney Disease In these patients, three 10-ram and one 5mm ports are required. It is necessary to have one 10-ram port in the anterior axillary line midway between the 12th rib and iliac crest through which a fan retractor is used for the kidney. The polycystic kidney is easily identified and Gerota's fascia incised. Initially, the posterior aspect of the kidney is dissected,
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followed by the polar regions, lateral surface, and anterior surface in that order. The major portion of the walls of larger cysts is excised using diathermy scissors, and the edges are fulgurated. Several small cysts are simply punctured with a diathermy hook, and no attempt is made to unroof them formally. An ultrasound unit is helpful in guiding the unroofing of large deeper cysts and perihilar cysts. Recently, in one case, the author used a neodymium-yttrium aluminum garnet laser for unroofing, marsupializing, and draining the cysts. The advantage of the laser is that it produces minimal smoke in comparison with diathermy, which minimizes the need to empty the retroperitoneal space frequently to get rid of the smoke. In patients with infected cysts, pus is aspirated for culture and sensitivity. The cysts are then approached in a similar fashion as described earlier. The retroperitoneal space is irrigated with copious amounts of saline. Perirenal fat is tacked to the residual cavity of the larger cysts wherever possible. Hemostasis is secured, and the procedure is concluded after placing a 14-F tube drain.
Indeterminate Renal Cysts Laparoscopic evaluation of indeterminate renal cysts can be performed by a retroperitoneal access (see Fig. 2). The perinephric fat overlying the kidney is dissected off the cyst and the surrounding parenchyma. Once the cyst is visible, the fluid is aspirated for cytologic analysis. The exposed cyst is then excised and sent for frozen section histopathologic examination. The interior and base of the lesion are thoroughly inspected, and biopsies are performed.
Bosniak's Type IV Renal Cyst or Malignant Cyst In these cases, the balloon is inflated outside Gerota's fascia and the fascia incised parallel to the psoas muscle. The renal hilum is
identified by looking for pulsation of the aorta and renal artery in the gutter medial to the medial margin of the psoas. Blunt dissection in this area with a blunt dissector or a suction tip exposes the great vessels and the renal pedicle. A window is created around the renal pedicle and enlarged by blunt dissection, toward the kidney and the great vessels, so that adequate length of the renal vessels is bared. The renal artery is first cleared and six clips applied on it. It is then divided
between three clips on either side. If the renal vein does not become flat after this step, an attempt is made to look for an accessory renal artery that is usually present. Subsequently, the renal vein is similarly clipped and divided or divided by an endovascular stapler. The kidney is mobilized outside Gerota's fascia, taking care not to violate its integrity at any point. For upper pole renal cystic tumors, the adrenal is also included in the dissection. In such cases, special care is required to prevent avulsion of the adrenal vein during dissection and traction, and it is preferable to clip and divide this vessel at an early stage. Once the whole kidney is mobilized, the ureter is clipped and divided, and the specimen is freed in the retroperitoneum and transferred to an Endosac or Endocatch (US Surgical Corporation, Norwalk, CT) device. Subsequently, an incision is made between two ports and the specimen delivered intact through this space without morcellation.
TransperitonealTechnique The patient is placed supine, the peritoneal cavity is entered, and the patient is then positioned on the operating table at the 45 ° flank position. Initially, the procedure was perf o r m e d using four ports, although simple cysts can be treated using three ports. In cases of ADPKD, four ports are invariably needed. The kidney is exposed by mobilizing the colon medially. The technique is similar to that previously described. 21-24
Renal Cysts The various types of simple renal cysts can be marsupialized either by reflection of the colon medially or by dissection through the mesocolon. 17 The cyst may be identified as a bulge in Gerota's fascia. Gerota's fascia and perirenal fat are dissected off the cyst, which is punctured with the help of a needle under endovision. The fluid is sent for cytologic analysis, and the cyst wall is elevated, dissected, and excised off. The leftover wall is fulgurated and the base fulgurated with a cautery to prevent recurrence. Gerota's fascia, perirenal fat, or even omentum can be used to tack in the residual cavity for prevention of recurrence.
Peripelvic Cysts Sometimes, peripelvic cysts may be located in between hilar vessels. In such a situation,
LAPAROSCOPICMANAGEMENTOF RENALCYSTICDISEASE only partial excision of the cyst wall is possible. It is essential to fill the residual cavity by fixing perinephric fat or a polytetrafluoroethylene wick. 6, 15, 27 In contrast to a simple renal cyst, a peripelvic cyst is considered a contraindication to percutaneous sclerosis?, is These cysts can be managed effectively, although the procedure is more complex than decortication of simple renal cysts. The peripelvic cyst located near the hilum and pelvis requires more :.complicated, skillful, and challenging dissection
Autosomal Dominant Polycystic Kidney Disease Laparoscopy has afforded excellent results in the management of ADPKD. The transperitoneal approach is suggested to maximize the number of cysts deroofed in one sitting and to allow cyst marsupialization in the peritoneal cavity in an effort to decrease recurrence. The kidney size is large, and the transperitoneal approach offers an excellent exposure for optimum management. Because the goal is to achieve similar results as in open surgeryJ, 32 it is necessary to deroof as many cysts as possible. In a recent single-center review, 15 patients with ADPKD with preserved renal function underwent extensive unilateral or bilateral laparoscopic cyst marsupialization using five ports. An ultrasound was of immense help in guiding the unroofing of larger, deeper, and perihilar cysts. A median of 204 (range, 11-635) cysts were unroofed, marsupialized, or drained, resulting in effective reduction of pain, improvement in hypertension, and stabilization of renal function. 6
Indeterminate Cysts In a recent series, 35 patients with indeterminate cysts were evaluated laparoscopically. Under laparoscopic visualization, the cyst was located and aspirated, the fluid was sent for cytology, and a biopsy of the floor of the cyst was performed. Four patients w e r e found to have cystic renal cell carcinoma and underwent partial or radical nephrectomy in the same sitting. One patient required delayed nephrectomy on account of a change in the histopathology report. These patients have been followed up for an average of 20.2 months. There is no evidence of local recurrence or metastatic disease, suggesting that initial laparoscopic evaluation of complex
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cysts can save patients from undergoing unnecessary open surgery, a, 34
Bosniak Type IV or Malignant Cysts In this group of patients, the preoperative radiologic diagnosis is available, and laparoscopic radical nephrectomy can be performed by the well-established technique.
RESULTS Table 3 summarizes the current experience in the world literature on laparoscopic management of renal cystic disease. For simple cysts, most surgeons have used the transperitoneal route. The majority have been successful in achieving their objective, which, in most cases, is relief of pain. The size of the cysts has been variable but is usually larger than 8 cm. A substantial number of these patients have been treated earlier by aspiration alone or b y aspiration and sclerosing agents before laparoscopic surgery. There have been no major complications. Even the 3.5% rate reported by Fahlenkamp and coworkers 8 is acceptable because all of the complications were minor. This lack of complications should reaffirm the faith of urologists in the laparoscopic approach. Peripelvic cysts (Table 4) have not been widely treated using laparoscopy54,16 The operating time is long (170-338 minutes), but because there have been no complications and few recurrences, it is worthwhile to continue evaluation of the role of laparoscopy in this condition. The data on the management of ADPKD are scant (Table 5). In the series of 15 patients reported on by Dunn and co-workers, 6 60% had relief of pain with 84% attained stabilized renal function at more than 2 years of mean follow-up. Because h y p e r t e n s i o n also has been shown to improve and because no significant complications have been reported, the laparoscopic approach meets all of the principles of surgery in such cases.
DISCUSSION The opinions on surgical decompression of renal cysts in polycystic kidney disease have varied since the procedure was first introduced by Rovsing. 32 The procedure was repopularized by Bennett and co-workers 3 who
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Table 4. LAPAROSCOPIC MANAGEMENT OF PERIPELVIC CYSTS
Study
Number of Patients
Presentation
Access
Operating Time (minutes)
Blood Loss (mL)
Hospital Stay (days)
Result
Hemal et aP 4
5
Pain and obstruction
RP
170
140
20
Failed in one case as multiple cysts located anteromedially
Hoenig et a116
4
Ipsilateral pain and obstruction
RP, 1 TP, 3
338
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2.75
Recurrent at 8 weeks in one case dealt with by RP access
Rubenstein et a]33
1
Pain
TP
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Comment Multiple cysts located anteromedially may cause difficulty in handling by RP access Suggested that a TP approach may be preferable Polytetrafluoroethylene wick placed into cyst cavity
RP = retroperitoneal; TP = transperitoneal.
demonstrated pain relief in 81% of patients followed up for 18 months without a detrimental effect on renal function and associated with an improvement in hypertension and quality of life. Laparoscopy has afforded excellent results in the management of simple renal cysts, and the extension of this technique to ADPKD has been natural, with similar efficacy and reduced morbidity in comparison with open surgery. 6,15,18,27 In patients with refractory s y m p t o m a t i c cysts, the morbidity of the operation exceeds the morbidity of the disease. Such a scenario offers the opportunity to reduce the morbidity of surgery b y employing laparoscopic methods. Studies have demonstrated that laparoscopy is associated with less postoperative pain, quicker convalescence, and improved cosmetic results when compared with tradi-
tional incisional surgery. 24 Numerous reports on laparoscopic surgery for renal cysts are now available. These reports include both retroperitoneal and transperitoneal procedures with an excellent outcome. 5,s, 10,13,14,27,30,33,34,37 In select patients, needlescopic surgery with all the benefits of laparoscopy has proved safe and feasible for simple renal cyst managementY Various complications may occur owing to dissection and overzealous fulguration of the base2 7 Immediate recurrence may occur owing to incomplete handling, 22 and small bowel obstruction may be seen at the site of introduction of the trocar in the transperitoneal approach. 36 Reports of laparoscopic surgery for peripelvic cysts are scant. Only three patients by a retroperitoneoscopic approach and three pa-
Table 5. LAPAROSCOPIC MANAGEMENT OF AUTOSOMAL DOMINANT POLYCYSTIC KIDNEY DISEASE
Study D u n n et at 6
Number of Number Patients of Ports Access 15
Hypertension
Relief of Pain 60% One patient, no improvement 90% I m m e d i a t e 71% A t 5 months 57% A t 2 y e a r s 100% Immediate Recurred in one patient after 9 months
5
TP
Improved
L i f s o n et a127
8*
4
TP
Improved
H e m a l et al is
3f
3-4
RP
Improved
Stabilization of Renal Function
Follow-up
Complications
84%
2.2 y e a r s (0.5-5)
--
--
26 m o n t h s (3-63)
--
Stable, 2 Progression, 1
1-3 y e a r s
TP = transperitoneal; RP = retroperitoneal. *Three patients underwent repeat procedure for recurrence of pain. "tOf three patients, two had presented in emergency with fever and pain owing to infected autosomal dominant polycystic kidney disease.
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tients by a transperitoneal route have undergone ablation for peripelvic cystsJ 4, 16,33 The author has operated on five patients with peripelvic cysts retroperitoneoscopically, and three of these cases have been reported on earlier} 4 It is easy to handle the posteriorly located peripelvic cyst, but, sometimes, multiple cysts present anteromedially near the hilar vessels and may not allow complete decortication of cyst, leaving behind a residual cyst as seen in one of the author's patients. This failure was of no consequence because the patient was asymptomatic. It is reasonable to tag perirenal fat in the residual cyst cavity after deroofing. When excision is partial, excessive fulguration at the base should be avoided to minimize trauma to the underlying parenchyma or the collecting system; instead, fulguration should be limited to the edge of the cyst wall. The difficulty in managing peripelvic cysts is borne out by the paucity of reports in the literature and by the long operating time in the author's previously reported cases and in the report by Hoenig and co-workers} 4,16,33It has been suggested that, because of the medial location of these cysts, a transperitoneal approach is preferable to retroperitoneal access17; however, the author has achieved good long-term results in four of five patients with peripelvic cysts by a retroperitoneoscopic approach. A ureteric catheter was used in these cases for identification of the distorted collecting system and to recognize any intraoperative injury to the collecting system. The renal vessels splayed around the peripelvic cyst were identified with careful dissection. Laparoscopic renal cyst decortication for ADPKD relieves pain, improves hypertension, and stabilizes renal function. 6, 7 Longterm follow-up suggests that a repeat procedure may be necessary to maintain adequate control of symptoms in polycystic kidney disease. 27 Laparoscopic decortication seems safe and effective in the management of ADPKDrelated chronic pain and refractory cyst infection} 5 The retroperitoneoscopic route may be preferred in the presence of infected cysts to prevent intraperitoneal contamination. In fact, cyst abscesses, as reported earlier, probably are a contraindication for transperitoneal access} 5 Laparoscopic evaluation of complex cysts can save the patient from undergoing unnecessary open surgery. Laparoscopic biopsy of cystic renal cell carcinoma followed by open
surgery does not seem to increase the incidence of peritoneal seeding, tract recurrence, or distant metastases}, 34 Renal cysts containing stones or xanthogranulomatous infection are difficult to treat and sometimes necessitate partial nephrectomy} s Critical documentation of experience from a multicenter study and an international perspective of 139 and 50 patients, respectively, did not reveal any significant complications, s, 10 The rate of minor complications was 3.5% in the management of 139 cases, s making laparoscopy the ideal choice for the management of renal cystic diseases. Transperitoneal laparoscopic resection of renal cystic disease has been p e r f o r m e d widely, whereas retroperitoneoscopic removal is only recently reported} 4,16,29 The transperitoneal approach may not be ideal because it requires mobilization of the colon to expose the cyst and retraction of viscera for further dissection. There is also the possibility of spillage of renal contents in the virgin peritoneal cavity. SUMMARY
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,
LAPAROSCOPIC MANAGEMENT OF RENAL CYSTIC DISEASE
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 followup. 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.
References 1. Amar AD, Das S: Surgical management of benign renal cyst causing obstruction of the renal pelvis. Urology 14:429, 1984 2. Bellman GC, Yamaguchi R, Kaswick J: Laparoscopic evaluation of indeterminate renal cysts. Urology 45:1066, 1995 3. Bennett WM, Elzinga LW, Golper TA, et al: Reduction of cyst volume for symptomatic management of autosomal dominant polycystic kidney disease. J Urol 137:620, 1987 4. Bosniak MA: The current radiologic approach to renal cysts. Radiology 158:1, 1986 5. Consonni P, Nava L, Scattani V, et al: Percutaneous echo-guided drainage and sclerotherapy of symptomatic renal cysts: Critical comparison with laparoscopic treatment. Arch Ital Urol Androl 68:27, 1996 6. Dunn M, McDougall EM, Clayman RV: Laparoscopic cyst marsupialization for patients with autosomal dominant polycystic kidney disease. J Endourol 13:PS17-1, A1225, 1999 7. Elashry OM, Nakada SY, Wolf JS, et ah Laparoscopy for adult polycystic kidney disease: A promising alternative. Am J Kidney Dis 27:224, 1996 8. Fahlenkamp D, Rassweiler J, Fornara P, et al: Complications of laparoscopic procedures in urology: Experience with 2407 procedures at 4 German centers. Urol 162:765, 1999 9. Fontana D, Porpiglia F, Morra I: Treatment of simple renal cysts by percutaneous drainage with three repeated alcohol injections. Urology 53:904, 1999 10. Gill IS, Clayman RV, Albala DM: Retroperitoneal and pelvic extraperitoneal laparoscopy: An international perspective. Urology 52:566, 1998 11. Gill IS, Grune MT, Munch LC: Access technique for retroperitoneoscopy. J Urol 156:1120, 1996 12. Goel A, Hemal AK: Laparoscopic access: In Hemal AK (ed): Laparoscopic Urologic Surgery--Retroperitoneal and Transperitoneal, ed 1. New Delhi, BI, Churchill Livingstone, 2000, p 51 13. Goazzoni G, Montorsi F, Bergamschi F: Laparoscopic unroofing of simple renal cysts. Urology 43:154, 1994 14. Hemal AK, Aron M, Gupta NP, et al: The role of
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retroperitoneoscopy in the management of renal and adrenal pathology. BJU Int 83:929, 1999 15. Hemal AK, Gupta NP, Rajeev TP, et al: Retroperitoneoscopic management of infected cysts in adult polycystic kidney disease. Urol Int 62: 40, 1999 16. Hoenig DM, McDougall EM, Shalhav AL, et al: Laparoscopic ablation of peripelvic renal cysts. J Urol 158: 1345, •997 17. Hoenig DM, Leveillee RJ, Amaral JF, et al: Laparoscopic unroofing of symptomatic renal cysts: Three distinct surgical approaches. J Endourol 9:55, 1995 18. Hoenig DM, Elbahnsy AM, Shalhav AL, et al: Laparoscopic management of autosomal dominant polycystic kidney disease. J Endourol 11($126):6, 1997 19. Holmberg G, Hictala SO: Treatment of simple renal cysts by percutaneous puncture and instillation of bismuth phosphate. Scand J Urol Nephrol 23:207, 1989 20. Hulbert JC, Hunter D, Young AT, et al: Percutaneous intrarenal marsupialization of a perirenal cystic collection---endocystolysis. J Urol 139:1039, 1988 21. Joyce AD: Laparoscopic excision of renal cysts. In Hemal AK (ed): Laparoscopic Urologic Surgery-Retroperitoneal and Transperitoneal, ed 1. New Delhi, BI, Churchill Livingstone, 2000, p 123 22. Kattan SA: Immediate recurrence of simple renal cyst after laparoscopic unroofing. Stand J Urol Nephrol 30:415, 1996 23. Kavoussi LR, Clayman RV, Mikkelsen DJ, et al: Ureteronephroscopic marsupialization of obstructing peripelvic renal cyst. J Urol 146:411, 1991 24. Kerbl K, Clayman RV, McDougall EM, et al: Transperitoneal nephrectomy for benign disease of the kidney: A comparison of laparoscopic and open surgical technique. Urology 43:607, 1994 25. Kissane JM: The morphology of renal cystic disease. In Gardner KD Jr (ed): Cystic Diseases of the Kidney. New York, John Wiley, 1976, p 31 26. Laucks SP, McLachlen MSF: Aging and simple cysts of the kidney. Br J Radiol 54:12, 1981 27. Lifson BJ, Teichman JMH, Hulbert JC, et al: Role and long-term results of laparoscopic decortication in solitary cystic and autosomal dominant polycystic kidney disease. J Urol 159:702, 1998 28. McDougall EM, Elbahnasy AM, Clayman RV: Laparoscopic wedge resection and partial nephrectomy-the Washington University experience and review of the literature. J Soc Laparoendosc Surg 12:15, 1998 29. Munch LC, Gill IS, McRoberts JW: Laparoscopic retroperitoneal renal cystectomy. J Urol 151:135, 1994. 30. Ou YC, Yang CR, Chang YY, et al: The clinical experience of gaseous retroperitoneoscopic and gasless retroperitoneoscopy assisted unroofing of renal cyst. Chung Hua I Hsueh Tsa Chih 59:232, 1997 31. Pisani E, Trinchieri A, Zanetti G, et al: Laparoscopy of the kidney and the adrenal gland. Ann Urol (Paris) 29:56, 1995 32. Rovsing T: Treatment of multilocular renal cyst with multiple punctures. Hospitals tid 4:105, 1911 33. Rubenstein CS, Hulbert JC, Pharand D, et al: Laparoscopic ablation of symptomatic renal cysts. J Urol 150:1103, 1993 34. Santiago L, Yamaguchi R, Kaswick J, et al: Laparoscopic management of indeterminate renal cysts. Urology 52:379, 1998 35. Soble JJ, Gill IS: Needlescopic urology: Incorporating 2-mm instrument in laparoscopic surgery. Urology 52:187, 1998 36. Stout L, Laub DJ, Zimmeran PE: Small bowel ob-
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struction at the site of introduction of the trocar: An unusual complication of laparoscopy. J Urol (Paris) 100:151, 1994 37. Wada T, Kamiryo Y, Tsuchida M, et al: Laparoscopic
unroofing of a renal cyst. Hinyokika Kiyo 41:861, 1995 38. Wolf JS: Evaluation and management of solid and cystic renal masses. J Urol 159:1120, 1999
Address reprint requests to Ashok K. Hemal, MS, MCh, FACS Department of Urology All India Institute of Medical Sciences Ansari Nagar, New Delhi-110 029 India e-mail: [email protected]
0094-0143/01 $15.00 + .00
LAPAROSCOPIC M A N A G E M E N T OF RENAL CYSTIC DISEASE A s h o k K. H e m a l , MS, MCh, FACS
Renal cystic disease is a common incidental, radiographic, and postmortem finding. It is estimated that evidence of renal cysts exists in 50% of the adult population. 25 The increased use of imaging modalities such as ultrasonography and CT has produced a corresponding increase in the detection of renal cystic disease. Simple renal cysts occur with an incidence of at least 20% by age 40 years and 33% at age 60 years. 26 Most of these lesions are asymptomatic. At times, the lesions may be associated with dull renal angle pain, flank pain, hypertension, a palpable mass, hematuria, infection, and collecting system obstruction 19,33 Symptomatic renal cysts can be treated by percutaneous aspiration with or without injection of sclerosants, 9 percutaneous marsupializationy open surgery, 1 and, most recently, by laparoscopic surgery b y transperitoneal and retroperitoneal access. 9,14,33 Peripelvic cysts are rare forms of renal cysts that are more commonly associated with pain, obstruction, infection, and stone formation. 16 Owing to their proximity to the renal hilum, these cysts offer a challenge in management. Percutaneous aspiration and instillation of sclerosants is difficult because of the risk for injury to nearby vessels. Ureteronephroscopic23and percutaneous marsupialization 2°,23 have been described; however, such cysts have most commonly been treated by open surgery, i, 16 except recently b y laparo-
scopic ablation, both transperitoneally and retroperitoneally.14,16 Certain renal cysts can be associated with other pathologic conditions, such as autosoreal dominant polycystic kidney disease (ADPKD) and acquired cystic disease in chronic dialysis. 21 ADPKD is an important cause of renal failure accounting for approximately 9% to 10% of patients on chronic hemodialysis. Other clinical manifestations include hypertension, chronic pain, hematuria, urinary tract infection, stone formation, and cyst infection. The traditional management of these cases has included narcotic analgesics, antibiotics, needle aspiration of d o m i n a n t cysts, and open renal cyst decortication77, 32 Laparoscopic cyst decortication is another option with similar efficacy to open surgery and less morbidity. 6, is, 27
EVALUATION Renal cystic disease can be adequately evaluated with ultrasonographic techniques. 38 For more complicated lesions, renal CT is the cornerstone of diagnosis. Based on CT scan, renal cysts have been classified into four categories by Bosniak# Type I--This simple cyst is the most common and generally requires no treatment, although, rarely, a large simple cyst
From the Department of Urology, All India Institute of Medical Sciences, N e w Delhi, India
UROLOGIC CLINICS OF NORTH AMERICA VOLUME 28 • NUMBER 1 • FEBRUARY 2001
115
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causes symptoms or obstruction and requires intervention. Type II--This h o m o g e n o u s h y p e r d e n s e cyst has thin septations and fine calcification that do not enhance after intravenous injection of contrast medium. Type III--This multiloculated cystic mass or cyst has thick irregular calcifications, a thick wall, or nodularity. Type IV--A cyst associated with a solid component; such lesions are considered to be cystic malignancies and should be managed with radical nephrectomy. Magnetic resonance imaging can be used in patients with contrast allergy, an elevated serum creatinine level, or a hyperdense renal cyst. MR imaging also helps in evaluation of the cyst wall. The role of intravenous urography is limited; it depicts cystic diseases as space-occupying lesions or demonstrates compression. Ultrasound is the recommended imaging modality for reliable identification and follow-up of cystic lesions. Equivocal cysts raising the possibility of malignancy can be further evaluated with CT, but, if any doubts remain regarding the nature of the lesion, percutaneous aspiration or biopsy is advocated to provide a definitive answer. The sensitivity for the detection of malignancy using percutaneous techniques is 90%. The specificity for the determination of benign disease is 92%. 3s
INDICATIONS Depending on the symptoms, size, site, locations, number, presence of infection, suspicion of malignancy, and other associated pathologic conditions, the following renal cystic disorders can be managed by laparoscopic intervention: 1. Bosniak type I and II renal cysts--large symptomatic renal cysts (-> 10 cm in size) directly taken up for laparoscopic management; smaller symptomatic renal cysts treated by percutaneous aspiration alone or with a sclerosing agent, failing which laparoscopic resection can be undertaken 14 2. Indeterminate cystic masses evaluated laparoscopically and m a n a g e d according]y34 3. Renal cystic masses with malignancy-treated by laparoscopic radical nephrectomy 1°
Table 1. OPERATIVE STEPS FOR RETROPERITONEOSCOPIC RENAL CYST MANAGEMENT
I. II. III. IV. V. VI. VII. VIII. IX. X. XI.
Position of patient Creation of retroperitoneal space Secondary port placement Kidney identification Identification and dissection of the cyst Aspiration and further dissection Excision/near-total resection/marsupialization/ deroofing Hemostasis/fulguration of cyst edge and wall Tacking of perirenal fat/polytetrafluoroethylene wick Drain placement (optional) Exiting the retroperitoneum
4. Peripelvic or parapelvic cysts 16 5. ADPKD 6 6. Renal hydatid cysts Laparoscopic evaluation, marsupialization, excision, and radical nephrectomy for a cystic mass harboring malignancy offer a definitive treatment for patients who have renal cystic diseases and can obviate open surgery.
LAPAROSCOPIC TECHNIQUES OF MANAGEMENT The laparoscopic approach is far less invasive than open surgery for an appropriate case of renal cystic disease. The approach may be retroperitoneoscopic or transperitoneal. The operative steps of these accesses are described in Tables 1 and 2.
Retroperitoneoscopic Technique The patient is placed in the standard flank position, the kidney bridge is elevated, and
Table 2. OPERATIVE STEPS FOR LAPAROSCOPIC RENAL CYST EXCISION OR DECORTICATION BY TRANSPERITONEAL ROUTE
I. II. III. IV. V. VI. VII. VIII. IX. X. XI.
Position of patient Pneumoperitoneum/primary port placement Secondary port placement Incision of the line of Toldt Identification of kidney/opening Gerota's fascia Identification and dissection of the cyst Aspiration and further dissection Excision/cyst decorticafion or deroofing Hemostasis / fulguration Tacking of perirenal fat Exiting the abdomen
LAPAROSCOPIC MANAGEMENT OF RENAL CYSTIC DISEASE
the operating table is flexed to maximize the space between the lowermost rib and the iliac crest. A 1.5- to 2-cm incision is made an inch below and posterior to the tip of the 12th rib for the primary port. The incision is deepened down to the thoracolumbar fascia and further developed posteriorly and toward both poles using a Clutton's dilator or digital dissection. Subsequently, a home-made balloon created by tying two finger stalks of a size 7.5 latex glove one inside the other over a catheter is inserted in the space created. The balloon is inflated with 300 to 400 mL of saline for 5 minutes to create adequate space in the retroperitoneum and secure hemostasis. If feasible, especially in a thin patient, the balloon is placed underneath Gerota's fascia. The custom-made balloon is used to reduce the cost; otherwise, the surgeon can use a trocarmounted dilator balloon device (Origin Medsystems, Menlo Park, CA) for creating a working space in the retroperitoneum. The balloon is removed, and a 10-ram blunt tip trocar (Origin Medsystems) is placed as the primary port. The trocar's balloon seals the incision, preventing leakage of gas. To reduce the cost, the author uses a reusable cannula as a primary port. The cannula is stabilized with two preplaced sutures of 1 / 0 nylon through the parietal musculature and thoracolumbar fascia, preventing the extravasation of carbon dioxide (CO2), leading to subcutaneous emphysema and preventing leakage b y the side of the port. The author prefers to place the secondary ports under laparoendovision. The second port may be placed parallel to the primary port in the posterior axillary line, at least 3 cm above the iliac crest to allow maneuverability. The third port can be placed in the midaxillary line according to the location of the cyst at the lower or upper pole. In most cases, surgery can be performed with three ports. A fourth port is optional. In the three-port technique, it is necessary to have two ports of 10 to 11 mm in size. The surgeon should be careful to avoid transgression of peritoneum during secondary port placement. The advantages of the retroperitoneoscopic technique are as follows: 1. It offers direct access to the retroperitoneally located genitourinary organs with no need for peritoneal entry or colonic mobilization. 2. The potential for intraperitoneal organ (visceral and vascular) injury is minimized.
117
3. The possibility of spillage of renal cystic fluid into the peritoneal cavity is eliminated, and postoperative hematoma or urinoma is confined to the retroperitoneum. 4. The risk for future adhesive obstruction and hernia is decreased. 5. The route can be used in patients who have undergone transperitoneal abdominal operations.
Disadvantages The relatively small working space in the retroperitoneoscopic approach may cause difficulty in mobilizing a large kidney, such as in ADPKD, for complete deroofing of the cyst. Sometimes, anteromedially located renal cysts and peripelvic cysts m a y create difficulty while attempting to excise the cysts completely.
Renal Cysts If the retroperitoneal space is created underneath Gerota's fascia, the kidney lies directly in front; otherwise, the overlying fascia of Gerota is usually thinned out, and the bluedomed cysts are easily recognized. Gerota's fascia is divided in relation to the location of the cyst. If the cyst is located anteriorly, medially, or anteromedially, the kidney is mobilized on the lateral border and retracted posteriorly with the help of a triflanged retractor to delineate the anterior surface of kidney. When doubt remains concerning the nature of the cyst, u n d e r laparoendovision, percutaneous puncture of the cyst is undertaken and the fluid sent for analysis and cytologic examination. The location of the cyst can also be confirmed with the help of laparoscopic ultrasound. A totally intrarenal cyst is a contraindication to a primary laparoscopic approach. The basic steps for the various types of renal cysts (Figs. 1-4) are the same; however, the clinician should be aware of anatomy preoperatively. A combination of blunt and sharp dissection using a dissector and scissor permits rapid and complete mobilization of the cyst surface. When the cyst is very tense, after initial exposure, it can be p u n c t u r e d and grasped with the help of an atraumatic dissector that provides countertraction for further dissection. The renal cyst can be further treated in the following ways.
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, The renal cyst can be completely excised when a good plane of cleavage can be developed between the cyst and the underlying parenchyma (see Fig. 3), • If the previous maneuver is not possible, near-total excision of the cyst wall is performed to avoid damage to the underlying collecting system or renal p a r e m chyma, tn these cases, the edges and base of the residual cyst wall are fulgurated. The surgeon should be extremely cautious while fulgurating the base because it overlies renal parenchyma and is in
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close proximity to the pelvicaliceal system. • The renal cyst can be marsupialized by excising the wall To decrease the possibility of recurrence, sub~ sequent to excision or marsupialization, peri~ nephric fat is tacked into the cavity,
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LAPAROSCOPICMANAGEMENTOF RENALCYSTICDISEASE
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dissection in patients with peripelvic cysts (Fig. 4). The presence of a ureteral catheter is of great help in identifying the compressed and distorted collecting system. The splayed out renal vessels are identified by careful dissection alone. If available, the clinician can employ a laparoultrasound probe to identify these vessels. Because the cysts are deeply ensconced in the renal sinus, aggressive resection of the cyst wall should not be attempted; instead, incomplete excision of cyst wall or marsupialization must be performed. To prevent recurrence, a pedicle of perirenal fat is placed in the cavity. At the end of the procedure, sterile methylene blue is injected through the preplaced ureteral catheter to identify any leak from the pelvicaliceal system.
Renal Hydatid Cyst After exposing the cyst, the retroperitoneal space is filled with normal saline and the
cyst punctured under laparoendovision. The contents are aspirated out, and the cavity is refilled with dilute povidone-iodine solution and drained, washing it out completely. At this stage, the cyst is excised in the same manner as renal cysts, and the perirenal fat is tacked in the space created. Once again, the retroperitoneal space is washed with normal saline.
Autosomal Dominant Polycystic Kidney Disease In these patients, three 10-ram and one 5mm ports are required. It is necessary to have one 10-ram port in the anterior axillary line midway between the 12th rib and iliac crest through which a fan retractor is used for the kidney. The polycystic kidney is easily identified and Gerota's fascia incised. Initially, the posterior aspect of the kidney is dissected,
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followed by the polar regions, lateral surface, and anterior surface in that order. The major portion of the walls of larger cysts is excised using diathermy scissors, and the edges are fulgurated. Several small cysts are simply punctured with a diathermy hook, and no attempt is made to unroof them formally. An ultrasound unit is helpful in guiding the unroofing of large deeper cysts and perihilar cysts. Recently, in one case, the author used a neodymium-yttrium aluminum garnet laser for unroofing, marsupializing, and draining the cysts. The advantage of the laser is that it produces minimal smoke in comparison with diathermy, which minimizes the need to empty the retroperitoneal space frequently to get rid of the smoke. In patients with infected cysts, pus is aspirated for culture and sensitivity. The cysts are then approached in a similar fashion as described earlier. The retroperitoneal space is irrigated with copious amounts of saline. Perirenal fat is tacked to the residual cavity of the larger cysts wherever possible. Hemostasis is secured, and the procedure is concluded after placing a 14-F tube drain.
Indeterminate Renal Cysts Laparoscopic evaluation of indeterminate renal cysts can be performed by a retroperitoneal access (see Fig. 2). The perinephric fat overlying the kidney is dissected off the cyst and the surrounding parenchyma. Once the cyst is visible, the fluid is aspirated for cytologic analysis. The exposed cyst is then excised and sent for frozen section histopathologic examination. The interior and base of the lesion are thoroughly inspected, and biopsies are performed.
Bosniak's Type IV Renal Cyst or Malignant Cyst In these cases, the balloon is inflated outside Gerota's fascia and the fascia incised parallel to the psoas muscle. The renal hilum is
identified by looking for pulsation of the aorta and renal artery in the gutter medial to the medial margin of the psoas. Blunt dissection in this area with a blunt dissector or a suction tip exposes the great vessels and the renal pedicle. A window is created around the renal pedicle and enlarged by blunt dissection, toward the kidney and the great vessels, so that adequate length of the renal vessels is bared. The renal artery is first cleared and six clips applied on it. It is then divided
between three clips on either side. If the renal vein does not become flat after this step, an attempt is made to look for an accessory renal artery that is usually present. Subsequently, the renal vein is similarly clipped and divided or divided by an endovascular stapler. The kidney is mobilized outside Gerota's fascia, taking care not to violate its integrity at any point. For upper pole renal cystic tumors, the adrenal is also included in the dissection. In such cases, special care is required to prevent avulsion of the adrenal vein during dissection and traction, and it is preferable to clip and divide this vessel at an early stage. Once the whole kidney is mobilized, the ureter is clipped and divided, and the specimen is freed in the retroperitoneum and transferred to an Endosac or Endocatch (US Surgical Corporation, Norwalk, CT) device. Subsequently, an incision is made between two ports and the specimen delivered intact through this space without morcellation.
TransperitonealTechnique The patient is placed supine, the peritoneal cavity is entered, and the patient is then positioned on the operating table at the 45 ° flank position. Initially, the procedure was perf o r m e d using four ports, although simple cysts can be treated using three ports. In cases of ADPKD, four ports are invariably needed. The kidney is exposed by mobilizing the colon medially. The technique is similar to that previously described. 21-24
Renal Cysts The various types of simple renal cysts can be marsupialized either by reflection of the colon medially or by dissection through the mesocolon. 17 The cyst may be identified as a bulge in Gerota's fascia. Gerota's fascia and perirenal fat are dissected off the cyst, which is punctured with the help of a needle under endovision. The fluid is sent for cytologic analysis, and the cyst wall is elevated, dissected, and excised off. The leftover wall is fulgurated and the base fulgurated with a cautery to prevent recurrence. Gerota's fascia, perirenal fat, or even omentum can be used to tack in the residual cavity for prevention of recurrence.
Peripelvic Cysts Sometimes, peripelvic cysts may be located in between hilar vessels. In such a situation,
LAPAROSCOPICMANAGEMENTOF RENALCYSTICDISEASE only partial excision of the cyst wall is possible. It is essential to fill the residual cavity by fixing perinephric fat or a polytetrafluoroethylene wick. 6, 15, 27 In contrast to a simple renal cyst, a peripelvic cyst is considered a contraindication to percutaneous sclerosis?, is These cysts can be managed effectively, although the procedure is more complex than decortication of simple renal cysts. The peripelvic cyst located near the hilum and pelvis requires more :.complicated, skillful, and challenging dissection
Autosomal Dominant Polycystic Kidney Disease Laparoscopy has afforded excellent results in the management of ADPKD. The transperitoneal approach is suggested to maximize the number of cysts deroofed in one sitting and to allow cyst marsupialization in the peritoneal cavity in an effort to decrease recurrence. The kidney size is large, and the transperitoneal approach offers an excellent exposure for optimum management. Because the goal is to achieve similar results as in open surgeryJ, 32 it is necessary to deroof as many cysts as possible. In a recent single-center review, 15 patients with ADPKD with preserved renal function underwent extensive unilateral or bilateral laparoscopic cyst marsupialization using five ports. An ultrasound was of immense help in guiding the unroofing of larger, deeper, and perihilar cysts. A median of 204 (range, 11-635) cysts were unroofed, marsupialized, or drained, resulting in effective reduction of pain, improvement in hypertension, and stabilization of renal function. 6
Indeterminate Cysts In a recent series, 35 patients with indeterminate cysts were evaluated laparoscopically. Under laparoscopic visualization, the cyst was located and aspirated, the fluid was sent for cytology, and a biopsy of the floor of the cyst was performed. Four patients w e r e found to have cystic renal cell carcinoma and underwent partial or radical nephrectomy in the same sitting. One patient required delayed nephrectomy on account of a change in the histopathology report. These patients have been followed up for an average of 20.2 months. There is no evidence of local recurrence or metastatic disease, suggesting that initial laparoscopic evaluation of complex
121
cysts can save patients from undergoing unnecessary open surgery, a, 34
Bosniak Type IV or Malignant Cysts In this group of patients, the preoperative radiologic diagnosis is available, and laparoscopic radical nephrectomy can be performed by the well-established technique.
RESULTS Table 3 summarizes the current experience in the world literature on laparoscopic management of renal cystic disease. For simple cysts, most surgeons have used the transperitoneal route. The majority have been successful in achieving their objective, which, in most cases, is relief of pain. The size of the cysts has been variable but is usually larger than 8 cm. A substantial number of these patients have been treated earlier by aspiration alone or b y aspiration and sclerosing agents before laparoscopic surgery. There have been no major complications. Even the 3.5% rate reported by Fahlenkamp and coworkers 8 is acceptable because all of the complications were minor. This lack of complications should reaffirm the faith of urologists in the laparoscopic approach. Peripelvic cysts (Table 4) have not been widely treated using laparoscopy54,16 The operating time is long (170-338 minutes), but because there have been no complications and few recurrences, it is worthwhile to continue evaluation of the role of laparoscopy in this condition. The data on the management of ADPKD are scant (Table 5). In the series of 15 patients reported on by Dunn and co-workers, 6 60% had relief of pain with 84% attained stabilized renal function at more than 2 years of mean follow-up. Because h y p e r t e n s i o n also has been shown to improve and because no significant complications have been reported, the laparoscopic approach meets all of the principles of surgery in such cases.
DISCUSSION The opinions on surgical decompression of renal cysts in polycystic kidney disease have varied since the procedure was first introduced by Rovsing. 32 The procedure was repopularized by Bennett and co-workers 3 who
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Table 4. LAPAROSCOPIC MANAGEMENT OF PERIPELVIC CYSTS
Study
Number of Patients
Presentation
Access
Operating Time (minutes)
Blood Loss (mL)
Hospital Stay (days)
Result
Hemal et aP 4
5
Pain and obstruction
RP
170
140
20
Failed in one case as multiple cysts located anteromedially
Hoenig et a116
4
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RP, 1 TP, 3
338
--
2.75
Recurrent at 8 weeks in one case dealt with by RP access
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1
Pain
TP
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Comment Multiple cysts located anteromedially may cause difficulty in handling by RP access Suggested that a TP approach may be preferable Polytetrafluoroethylene wick placed into cyst cavity
RP = retroperitoneal; TP = transperitoneal.
demonstrated pain relief in 81% of patients followed up for 18 months without a detrimental effect on renal function and associated with an improvement in hypertension and quality of life. Laparoscopy has afforded excellent results in the management of simple renal cysts, and the extension of this technique to ADPKD has been natural, with similar efficacy and reduced morbidity in comparison with open surgery. 6,15,18,27 In patients with refractory s y m p t o m a t i c cysts, the morbidity of the operation exceeds the morbidity of the disease. Such a scenario offers the opportunity to reduce the morbidity of surgery b y employing laparoscopic methods. Studies have demonstrated that laparoscopy is associated with less postoperative pain, quicker convalescence, and improved cosmetic results when compared with tradi-
tional incisional surgery. 24 Numerous reports on laparoscopic surgery for renal cysts are now available. These reports include both retroperitoneal and transperitoneal procedures with an excellent outcome. 5,s, 10,13,14,27,30,33,34,37 In select patients, needlescopic surgery with all the benefits of laparoscopy has proved safe and feasible for simple renal cyst managementY Various complications may occur owing to dissection and overzealous fulguration of the base2 7 Immediate recurrence may occur owing to incomplete handling, 22 and small bowel obstruction may be seen at the site of introduction of the trocar in the transperitoneal approach. 36 Reports of laparoscopic surgery for peripelvic cysts are scant. Only three patients by a retroperitoneoscopic approach and three pa-
Table 5. LAPAROSCOPIC MANAGEMENT OF AUTOSOMAL DOMINANT POLYCYSTIC KIDNEY DISEASE
Study D u n n et at 6
Number of Number Patients of Ports Access 15
Hypertension
Relief of Pain 60% One patient, no improvement 90% I m m e d i a t e 71% A t 5 months 57% A t 2 y e a r s 100% Immediate Recurred in one patient after 9 months
5
TP
Improved
L i f s o n et a127
8*
4
TP
Improved
H e m a l et al is
3f
3-4
RP
Improved
Stabilization of Renal Function
Follow-up
Complications
84%
2.2 y e a r s (0.5-5)
--
--
26 m o n t h s (3-63)
--
Stable, 2 Progression, 1
1-3 y e a r s
TP = transperitoneal; RP = retroperitoneal. *Three patients underwent repeat procedure for recurrence of pain. "tOf three patients, two had presented in emergency with fever and pain owing to infected autosomal dominant polycystic kidney disease.
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HEMAL
tients by a transperitoneal route have undergone ablation for peripelvic cystsJ 4, 16,33 The author has operated on five patients with peripelvic cysts retroperitoneoscopically, and three of these cases have been reported on earlier} 4 It is easy to handle the posteriorly located peripelvic cyst, but, sometimes, multiple cysts present anteromedially near the hilar vessels and may not allow complete decortication of cyst, leaving behind a residual cyst as seen in one of the author's patients. This failure was of no consequence because the patient was asymptomatic. It is reasonable to tag perirenal fat in the residual cyst cavity after deroofing. When excision is partial, excessive fulguration at the base should be avoided to minimize trauma to the underlying parenchyma or the collecting system; instead, fulguration should be limited to the edge of the cyst wall. The difficulty in managing peripelvic cysts is borne out by the paucity of reports in the literature and by the long operating time in the author's previously reported cases and in the report by Hoenig and co-workers} 4,16,33It has been suggested that, because of the medial location of these cysts, a transperitoneal approach is preferable to retroperitoneal access17; however, the author has achieved good long-term results in four of five patients with peripelvic cysts by a retroperitoneoscopic approach. A ureteric catheter was used in these cases for identification of the distorted collecting system and to recognize any intraoperative injury to the collecting system. The renal vessels splayed around the peripelvic cyst were identified with careful dissection. Laparoscopic renal cyst decortication for ADPKD relieves pain, improves hypertension, and stabilizes renal function. 6, 7 Longterm follow-up suggests that a repeat procedure may be necessary to maintain adequate control of symptoms in polycystic kidney disease. 27 Laparoscopic decortication seems safe and effective in the management of ADPKDrelated chronic pain and refractory cyst infection} 5 The retroperitoneoscopic route may be preferred in the presence of infected cysts to prevent intraperitoneal contamination. In fact, cyst abscesses, as reported earlier, probably are a contraindication for transperitoneal access} 5 Laparoscopic evaluation of complex cysts can save the patient from undergoing unnecessary open surgery. Laparoscopic biopsy of cystic renal cell carcinoma followed by open
surgery does not seem to increase the incidence of peritoneal seeding, tract recurrence, or distant metastases}, 34 Renal cysts containing stones or xanthogranulomatous infection are difficult to treat and sometimes necessitate partial nephrectomy} s Critical documentation of experience from a multicenter study and an international perspective of 139 and 50 patients, respectively, did not reveal any significant complications, s, 10 The rate of minor complications was 3.5% in the management of 139 cases, s making laparoscopy the ideal choice for the management of renal cystic diseases. Transperitoneal laparoscopic resection of renal cystic disease has been p e r f o r m e d widely, whereas retroperitoneoscopic removal is only recently reported} 4,16,29 The transperitoneal approach may not be ideal because it requires mobilization of the colon to expose the cyst and retraction of viscera for further dissection. There is also the possibility of spillage of renal contents in the virgin peritoneal cavity. SUMMARY
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,
LAPAROSCOPIC MANAGEMENT OF RENAL CYSTIC DISEASE
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 followup. 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.
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Address reprint requests to Ashok K. Hemal, MS, MCh, FACS Department of Urology All India Institute of Medical Sciences Ansari Nagar, New Delhi-110 029 India e-mail: [email protected]