- Email: [email protected]
Laparoscopic nephrectomy in patients with end-stage renal disease and autosomal dominant polycystic kidney disease
Laparoscopic Nephrectomy in Patients With End-Stage Renal Disease and Autosomal Dominant Polycystic Kidney Disease Matthew D. Dunn, MD, Andrew J. Portis, MD, Abdelhamid M. Elbahnasy, MD, Arieh L. Shalhav, MD, Marcos Rothstein, MD, Elspeth M. McDougall, MD, and Ralph V. Clayman, MD ● Autosomal dominant polycystic kidney disease (ADPKD) is often characterized by end-stage renal disease (ESRD) and problems including pain, hematuria, and infection. Open nephrectomy is curative; however, the morbidity of the procedure is considerable. Between 1995 and 1998, 11 laparoscopic nephrectomies were performed on nine symptomatic patients (five men and four women) with ESRD and ADPKD. Two patients underwent a staged bilateral laparoscopic nephrectomy. All patients presented with abdominal or flank pain and an abdominal mass. Other clinical problems included hypertension in eight patients, urinary tract infections in two patients, and gross hematuria in one patient. Seven patients were receiving long-term dialysis treatment, and two patients had undergone prior renal transplantation. Patients were evaluated for preoperative and postoperative pain, analgesic use, hospital course, and convalescence. The overall average operative time was 6.3 hours, with an average estimated blood loss of 153 mL. Eight nephrectomy specimens were removed by morcellation, and three specimens were removed intact through a 7- to 12-cm incision. The average hospital stay was 3 days, and the average time to normal activity was 5 weeks. With a mean follow-up of 31 months, all nine patients reported elimination of their preoperative pain based on a pain analogue score. Six major and two minor complications occurred, including blood transfusion, a vena cavotomy, splenic cyanosis, pulmonary embolism, clotted arteriovenous fistula, and brachial plexus injury. Incisional hernias occurred in two of the three patients who underwent open removal. One patient noted improvement, and two patients noted resolution of their hypertension postoperatively. Laparoscopic nephrectomy in patients with ADPKD and ESRD offers an effective alternative to open nephrectomy to manage renal-related pain. This procedure provides the benefits of minimal intraoperative blood loss, minimal postoperative pain, brief hospital stay, and rapid convalescence. 娀 2000 by the National Kidney Foundation, Inc. INDEX WORDS: Polycystic kidney disease; laparoscopy; nephrectomy.
Editorial, p. 770
I
N PATIENTS WITH autosomal dominant polycystic kidney disease (ADPKD), flank or abdominal pain is the most common presenting symptom.1 The cause of the pain is unclear, but it is usually attributed to the massive enlargement of the kidney from the renal cysts, which may stretch the renal capsule, produce traction on the renal pedicle, or partially occlude parts of the collecting system. Hypertension also commonly occurs. Patients with hypertension have
From the Department of Surgery/Division of Urologic Surgery, the Department of Radiology (Mallinckrodt Institute of Radiology, and the Department of Internal Medicine, Renal Division, Washington University School of Medicine, St. Louis, MO; and the Department of Urology, Tanta University, Tanta, Egypt. Received June 24, 1999; accepted in revised form October 25, 1999. Address reprint requests to Ralph V. Clayman, MD, Washington University School of Medicine, Division of Urology, 4960 Children’s Place, St Louis, MO 63110. E-mail: [email protected]
娀 2000 by the National Kidney Foundation, Inc. 0272-6386/00/3504-0020$3.00/0 720
more cysts than normotensive ADPKD patients, and are more prone to developing renal insufficiency.2 Urolithiasis, hematuria, urinary tract infections, and palpable renal masses are other associated problems. End-stage renal disease (ESRD) is the major late outcome of ADPKD patients; 45% of ADPKD patients develop renal insufficiency by 60 years of age and progress to dialysis or renal transplantation.3 Unfortunately, many of these patients, despite their renal failure, continue to complain of marked flank discomfort. Nephrectomy in ADPKD is curative of the pain. However, it is a significantly more difficult procedure because of the size of the kidneys and the compromised state of the patient, who is commonly on dialysis or immunosuppression therapy because of renal transplantation. We reported the first case of laparoscopic nephrectomy in a patient with ADPKD in 1996.4 Since that time we have successfully completed this procedure in another eight ADPKD patients. MATERIALS AND METHODS Between March 1995 and April 1998, nine ADPKD patients underwent 11 laparoscopic nephrectomies; seven patients underwent a unilateral nephrectomy, and two patients underwent a staged bilateral nephrectomy (Table 1).
American Journal of Kidney Diseases, Vol 35, No 4 (April), 2000: pp 720-725
LAPAROSCOPIC NEPHRECTOMY IN ADPKD AND ESRD Table 1. Patient Demographics Laparoscopic Nephrectomy
No. of patients/procedures Sex (M/F) Mean age (y) Side Right Left Staged bilateral Presentation Pain HTN UTI/stone Abdominal mass Renal failure GI symptoms (early satiety) Previous surgical intervention
9/11 5/4 53 (45-73) 2 5 2 9 (100%) 8 (89%) 3 (33%) 9 (100%) 7 (78%)* 2 (22%) Open cyst reduction (3) Percutaneous cyst drainage (1)†
*Two patients had a renal transplant before laparoscopic nephrectomy. †Percutaneous cyst drainage was performed 1 month before laparoscopic nephrectomy.
Ten procedures were approached transperitoneally, and one nephrectomy was performed through a retroperitoneal approach. The latter was in a patient with a history of an abdominal hernia repair with Marlex mesh. All patients complained of flank or abdominal pain, but only four patients were regularly using oral narcotic analgesics (Vicodin, Knoll Pharmaceuticals, Mt Olive, NJ; Dilaudid, Knoll; Tylox, Ortho McNeil, Raritan, NJ) preoperatively. Eight of the nine patients presented with hypertension, seven of which were managed with oral agents. Other presentations included recurrent urinary tract infections in three patients, nephrolithiasis in two patients, and macroscopic hematuria in one patient. Two patients complained of early satiety and abdominal distension. Three patients underwent open cyst marsupialization before nephrectomy (in 1960, 1988, and 1992, respectively); earlier in our experience (1996), one patient underwent percutaneous drainage of large cysts 1 month before nephrectomy to reduce the size of the kidneys in preparation for the laparoscopic nephrectomy. Seven patients were on long-term hemodialysis, and two patients had undergone a cadaveric renal transplantation before nephrectomy. Of the latter, one patient underwent transplantation 6 years before nephrectomy, and the other patient underwent transplantation 2 years before the second nephrectomy. Overall, these patients had a 1- to 12-month history of end-stage renal failure before nephrectomy.
Current Operative Technique for Laparoscopic Nephrectomy Our preferred approach is transperitoneal, as was done in 10 of the 11 nephrectomies. A transumbilical pneumoperito-
721
neum is created with the patient in the supine position to avoid injury to the massively enlarged kidneys. The patient is then repositioned and three 12-mm ports and two 5-mm ports are inserted. After medial mobilization of the colon, the anterior surface of the kidney is cleared of Gerota’s fascia and perirenal fat. In situ aspiration of the anterior nonhilar cysts is done to reduce the size of the kidney and thereby facilitate further mobilization of the kidney to access the renal vessels. The renal hilum is then dissected, and the renal artery is secured with five laparoscopic clips (9 mm) while the renal vein is occluded with a laparoscopic vascular stapler. The ipsilateral adrenal gland is spared. Dissection is continued along the lower and upper pole of the kidney, additionally draining large cysts. The posterior surface of the kidney is then dissected and cysts along the surface are aspirated or unroofed. The ureter is then divided between two laparoscopic 9-mm clips. Next, an 8 ⫻ 10-inch LapSac (Cook Urological Inc, Spencer, IN) is placed in the abdomen and opened. The kidney is manipulated into the sack and morcellated with either mechanical forceps or an electrical tissue morcellator (Cook Urological Inc, Spencer, IN). In our first three patients, the specimen was retrieved intact via a 7- to 12-cm ipsilateral lower quadrant incision. In one patient with multiple giant hepatic cysts, laparoscopic marsupialization of the hepatic cysts was performed in the supine position first. The patient was then repositioned to the lateral position for the laparoscopic nephrectomy. For follow-up evaluation, patients were mailed a questionnaire assessing their postoperative pain, quality of life, and current medical condition. In addition, all patients underwent a phone call evaluation to assess the same parameters. Pain was assessed using a standardized pain analogue scale (0 to 10), with 0 indicating no pain and 10 indicating the worst pain.
RESULTS
Overall, the mean operating room (OR) time was 6.3 hours (Table 2), with a mean estimated blood loss (EBL) of 153 mL. This excludes the single patient who underwent simultaneous laparoscopic nephrectomy and hepatic cyst marsupialization. In that patient, OR time was 6.8 hours and EBL was 150 mL. For the intact removal group (3 cases), OR time and EBL averaged 7.0 hours and 300 mL, respectively. Likewise, for the morcellated group (8 cases), the mean OR time and EBL were 6.1 hours and 132 mL, respectively. The overall average specimen weight was 769 g, with a range of 132 to 2,200 g. This wide range was dependent on the number of cysts drained during the procedure and whether the specimen was removed intact or entrapped and morcellated. For intact removal, the average specimen weighed 1,382 g, whereas the morcellated specimens averaged only 539 g. From experience, it has now become our practice to reduce
722
DUNN ET AL Table 2. Operative Data
Approach: Transperitoneal Retroperitoneal OR time (h) EBL (mL) Specimen weight (g)
Laparoscopic Nephrectomy (11 procedures)
Intact Removal (3 procedures)
Morcellated (8 procedures)
10 procedures 1 procedure 6.3 (3.4-8.8)* 153 (50-500)* 769 (132-2,200)
2 1 6.3 and 7.7* 100 and 500* 1,382 (750-2200)
8 0 6.1 (3.4-8.8) 132 (50-200) 539 (132-985)†
*Excludes one patient in whom hepatic cysts were also unroofed at the time of the nephrectomy, which resulted in a total operative time of 6.8 hours and EBL of 150 mL. †Does not include cyst fluid, which is aspirated at the time of morcellation.
the specimen size through aspiration of cyst fluid in situ, so that the kidney can be entrapped, morcellated, and evacuated through one of the 12-mm port sites, thereby precluding the need to make a sizable incision. The postoperative hospital course is illustrated in Table 3. For the whole group, average time to oral intake was 19 hours, and postoperative parenteral analgesia requirement averaged 33 mgMSEq. (equivalents of morphine sulfate: 1 mgMS ⫽ 10 mg meperidine). Time to oral intake for the intact removal versus the morcellated group was 20 hours and 19 hours, respectively. Average analgesic requirement in the intact removal group was 42 mg and 29 mg in the morcellated group. The average hospital stay was 3 days and was essentially similar for the patients whose specimens were removed intact (3.7 days) or morcellated (3.3 days). Two intraoperative complications occurred. In one patient, a small vena cavotomy occurred, which was controlled laparoscopically with the EndoStitch (Ethicon Endosurgery, Cincinnati,
OH) suturing device. The EBL was 500 mL for that patient, and a blood transfusion of 2 units was required in the immediate postoperative period. The other intraoperative complication was splenic cyanosis after mobilizing the superior pole of the kidney near the splenic hilum. An intraoperative general surgery consult was obtained and recommended no further management because there was no hemorrhage. The subsequent postoperative course for that patient was unremarkable; no postoperative imaging was obtained. One patient developed a brachial plexus injury noted immediately postoperatively which has persisted, although mildly improved, 12 months later. One patient developed occlusion of his hemodialysis shunt on the day after surgery which was subsequently revised at an outside hospital closer to the patient’s home. Other complications included pulmonary embolism in one patient, which was managed medically with systemic and then oral anticoagulation. Two of the three patients who had intact removal of their specimens devel-
Table 3. Hospital Course Laparoscopic Nephrectomy (11 procedures)
Oral intake (h) Parenteral analgesia (mgMS equivalent) Hospital stay (d) Complications (total no.)
Pathology
Intact Removal (3 procedures)
Morcellated (8 procedures)
19 (8-36)
20 (8-36)
19 (8-24)
33 mg (5-100) 3 (2-5) 6
42 mg (5-100) 3.7 (3-4) 1 (vena cavotomy) 1 (blood transfusion)
29 mg (5-44) 3.3 (2-5) 1 (pulmonary embolism) 1 (splenic cyanosis) 1 (brachial plexus injury, persistent) 7—benign 1—RCC (papillary)
Benign—10 kidneys RCC (papillary)—1 kidney
1 (occluded dialysis shunt) 3—benign
LAPAROSCOPIC NEPHRECTOMY IN ADPKD AND ESRD
oped postoperative incisional hernias. One patient underwent open surgical repair, and the other has refused any repair because she is asymptomatic. With respect to final pathology, 1 specimen had grade 1, papillary renal cell carcinoma, whereas the remaining 10 specimens were all benign. The former patient ultimately underwent open nephrectomy of the contralateral kidney at an outside institution 7 months after the laparoscopic nephrectomy. This was out of concern for possible tumor in the other kidney, although pathology for that specimen was benign. At 20 months follow-up, this patient has no physical or radiographic sign of tumor recurrence. With a mean follow-up of 31 months, all 9 patients reported complete resolution of their preoperative pain on the side of surgery (0 on a scale of 0-10; Table 4). One patient underwent open removal of the contralateral kidney emergently for hemorrhage approximately 9 months after the original laparoscopic nephrectomy. Five of seven dialysis patients progressed to renal transplantation, 7 to 12 months after laparoscopic nephrectomy. Among eight patients with preoperative hypertension, hypertension was unchanged (taking same medication) in 2 patients (25%), improved in one patient (12.5%) (decreased number of medications), and resolved in two patients (25%) (off all blood pressure medication). Of the two patients who underwent bilateral nephrectomies, the hypertension improved in one and resolved in the other, each only after the second nephrectomy. Three patients (37.5%)
723
had worsening of their blood pressure control. Two of these patients required additional medication; the other, who was mildly hypertensive and not on medication preoperatively, needed medication within 6 months after surgery. The one patient without preoperative hypertension remains normotensive. DISCUSSION
Abdominal discomfort and flank pain are found in half to 60% of all patients with ADPKD, necessitating the use of nonsteroidal anti-inflammatory agents and narcotic analgesics.1,5 Additionally, hypertension occurs in 60% of these patients which is usually cyst related. For patients with ESRD and medically refractory flank pain, open nephrectomy is usually the next course of action. However, because of the large size of the kidneys and the high risk of these patients (ie, on dialysis or postrenal transplantation), nephrectomy is associated with high morbidity and mortality rates (12% and 5%, respectively).6,7 In part because of these problems, the nephrectomy rate in ADPKD patients with ESRD decreased from 85% in the early 1970s to only 47% in the late 1980s.8 Laparoscopic nephrectomy was first performed in 1990.9 Since that time, laparoscopic simple nephrectomy has become widely accepted and practiced.10 In addition, larger kidneys have been approached and successfully removed as the indications for laparoscopic nephrectomy have been extended to include patients with renal cell can-
Table 4. Postoperative Follow-Up Laparoscopic Nephrectomy (11 procedures)
Mean follow-up (mo) Time to normal activity* (wk) Pain relief (%)† HTN status Resolved Improved Same Deteriorated Late complications
31 (14-49) 5 (1-12) 100 (8 patients) 2 (25%) 1 (12.5%) 2 (25%) 3 (37.5%) 3
Intact Removal (3 procedures)
Morcellated (8 procedures)
48 (47-49) 3.5 (3-4) 100
25 (14-42) 5 (1-12) 100
1 2 (incisional hernias)
2 1 1 3 1 (brachial nerve palsy, persistent)
*Assessed retrospectively at the time of the questionnaire or phone call evaluation. †Based on a pain analog scale by mailed questionnaire or phone call evaluation on two separate occasions at least 6 months apart.
724
cer up to 7 cm.11 Indeed, specimens as large as 1,500 g have been successfully removed.12 Extension of laparoscopic nephrectomy to patients with ADPKD was first reported by Elashry and colleagues4 in 1995 with the laparoscopic intact removal of a 2,200-g specimen from a 15-cm incision.4 Operative time for this patient was 487 minutes, hospital stay was 3 days, and return to normal activity occurred in 4 weeks. Unfortunately, this patient also developed a postoperative incisional hernia at the site of intact removal. Since our initial report, we have changed our technique in one important aspect. We have abandoned intact removal in exchange for widespread cyst drainage, entrapment, and morcellation. We believe this should eliminate any further problems of wound hernia formation. In comparing our experience with the initial three cases of intact removal with the subsequent eight cases of morcellation, there was a reduction in the blood loss, operative time, and postoperative use of parenteral analgesics in the morcellation group. This difference is likely a reflection of our increased experience, the time saved by not having to close the 7- to 12-cm incision, and the decreased size of the operative wounds. This approach should also limit the wound-related problems, which accounted for almost half of our patients’ postoperative complications. The occurrence of a brachial plexus injury reinforces the importance of proper patient positioning and padding. We routinely pad the axillary region as well as all extremities and pressure points. The arm is never extended more than 90° at the shoulder. Likewise, the patient is well secured to the table with straps to maintain positioning during table movements. Close attention must be paid to arm placement not only before surgery but also during surgery to ensure that shifts in body position have not occurred during the course of the operation. This is especially important in prolonged laparoscopic procedures. Laparoscopic procedures, certainly in their early stages, require more operative time to complete than their open counterparts. This is especially true in ADPKD because of the huge renal size, surrounding fibrosis, and proximity to several vital structures. This technical difficulty is reflected in the longer average operative times (6.3 hours) as compared with our more recent
DUNN ET AL
laparoscopic radical nephrectomy series, which is considerably shorter (4.5 hours).12 However, as shown in the laparoscopic versus open radical nephrectomy literature, this increased time expenditure is counterbalanced by a decrease in analgesic use, hospital stay, and convalescence.13,14 The problem of operating room efficiency, we believe, will improve as more urologists become adept at laparoscopic procedures. Also, the advent of hand-assisted laparoscopy will allow these procedures to be done more quickly by a larger number of urologists. Indeed, with the hand-assisted approach, several centers have now reported operating room times for radical nephrectomy in a range equivalent to open surgery. Preliminarily, our early experience concurs that the hand-assisted technique appears to facilitate the dissection and removal of these large kidneys. Recent literature has documented the problems experienced by ADPKD patients after transplantation. In one series, 47% of those ADPKD patients with a pretransplantation history of renal cyst–derived maladies (ie, pain, infection, hemorrhage) experienced cyst related problems posttransplantation; among those without pretransplantation cyst-related problems, these difficulties arose in 39% during the posttransplantation follow-up period. It appeared that nephrectomy before transplantation was of some benefit. Indeed, the 5-year graft survival and 5-year patient survival were improved by 19% and 18%, respectively, among those ADPKD patients undergoing pretransplantation nephrectomy.15 Hence, a case can be made for proceeding with a nephrectomy before transplantation for those patients with a history of unilateral cyst-related signs and symptoms. Given the effectiveness and excellent convalescence associated with the laparoscopic approach, we believe more patients with ADPKD and ESRD may become candidates for nephrectomy. CONCLUSION
Laparoscopic nephrectomy with morcellation for ADPKD can be accomplished successfully and safely. This technique offers ADPKD patients the potential benefits of minimal intraoperative blood loss, minimal postoperative pain, a brief hospital stay, and rapid convalescence while avoiding the typically large incision associated
LAPAROSCOPIC NEPHRECTOMY IN ADPKD AND ESRD
with this procedure when done by either open surgery or laparoscopic intact removal. REFERENCES 1. Gabow PA: Autosomal dominant polycystic kidney disease. N Engl J Med 329:332-342,1993 2. Bell PE, Hossach KE, Gabow PA, Durr JA, Johnson AM, Schrier RW: Hypertension in autosomal dominant polycystic kidney disease. Kidney Int 34:683-690, 1988 3. Parfrey PS, Bear JC, Morgan J, Carmer BC, McManamon PJ, Gault MH, Churchill DN, Singh M, Hewitt R, Somlo S, Reeders ST: The diagnosis and prognosis of autosomal dominant polycystic kidney disease. N Engl J Med 323:1085-1090, 1990 4. Elashry OM, Nakada SY, Wolf JS, McDougall EM, Clayman RV: Laparoscopy for adult polycystic kidney disease: A promising alternative. Am J Kidney Dis 27:224-233, 1996 5. Milutinovic J, Fialkow PJ, Agodoa LY, Phillips LA, Rudd TG, Sutherland S: Clinical manifestations of autosomal dominant polycystic kidney disease in patients older than 50 years. Am J Kidney Dis 15:237-243, 1990 6. Mendelssohn DC, Harding ME, Cardella CJ, Cook GT, Uldall PR: Management of end-stage autosomal dominant polycystic kidney disease with hemodialysis and transplantation. Clin Nephrol 30:315-319, 1988 7. Florjin KW, Chang PC, van der Woulde FJ, van Bockel JH, van Saase JLCM: Long-term cardiovascular morbidity and mortality in autosomal dominant polycystic kidney
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disease patients after renal transplantation. Transplantation 57:73-81, 1994 8. Ho-Hsieh H, Novick AC, Steinmuller D, Streem SB, Buszta C, Goomstic M: Renal transplantation for end stage polycystic kidney disease. Urology 30:322-326,1987 9. Clayman RV, Kavoussi LR, Soper NJ, Dierks SM, Meretyk S, Darcy MD, Long SR, Roemer FD, Pingleton ED, Thomson PG: Laparoscopic nephrectomy. N Engl J Med 324:1370-1372, 1991 (letter) 10. Eraky I, El-Kappany H, Shamaa MA, Ghoneim MA: Laparoscopic nephrectomy: an established routine procedure. J Endourology 8:275-279, 1994 11. Ono Y, Katoh N, Kinukawa T, Matsuura O, Ohshima S: Laparoscopic radical nephrectomy: The Nagoya experience. J Urol 158:719-724, 1997 12. Dunn MD, Portis AJ, Shalhav AL, Heidorn C, Elbahnasy AM, McDougall EM, Clayman RV: Laparoscopic vs. open radical nephrectomy: The Washington University experience. J Urol 161:S166, 1999 (abstr; suppl 4) 13. McDougall EM, Clayman RV, Elashry OM: Laparoscopic radical nephrectomy for renal tumor: The Washington University experience. J Urol 155:1180-1185, 1996 14. Ono Y, Kinukawa, T, Hattori R, Yamada S, Nishiyama N, Mizutani K, Ohshima S: Laparoscopic radical nephrectomy for renal cell carcinoma: A five year experience. Urology 53:280-286, 1999 15. Brazda E, Ofner D, Riedmann B, Spechtenhauser B, Margreiter R: The effect of nephrectomy on the outcome of renal transplantation in patients with polycystic kidney disease. Ann Transplant 1:15-18, 1996
Editorial, p. 770
I
N PATIENTS WITH autosomal dominant polycystic kidney disease (ADPKD), flank or abdominal pain is the most common presenting symptom.1 The cause of the pain is unclear, but it is usually attributed to the massive enlargement of the kidney from the renal cysts, which may stretch the renal capsule, produce traction on the renal pedicle, or partially occlude parts of the collecting system. Hypertension also commonly occurs. Patients with hypertension have
From the Department of Surgery/Division of Urologic Surgery, the Department of Radiology (Mallinckrodt Institute of Radiology, and the Department of Internal Medicine, Renal Division, Washington University School of Medicine, St. Louis, MO; and the Department of Urology, Tanta University, Tanta, Egypt. Received June 24, 1999; accepted in revised form October 25, 1999. Address reprint requests to Ralph V. Clayman, MD, Washington University School of Medicine, Division of Urology, 4960 Children’s Place, St Louis, MO 63110. E-mail: [email protected]
娀 2000 by the National Kidney Foundation, Inc. 0272-6386/00/3504-0020$3.00/0 720
more cysts than normotensive ADPKD patients, and are more prone to developing renal insufficiency.2 Urolithiasis, hematuria, urinary tract infections, and palpable renal masses are other associated problems. End-stage renal disease (ESRD) is the major late outcome of ADPKD patients; 45% of ADPKD patients develop renal insufficiency by 60 years of age and progress to dialysis or renal transplantation.3 Unfortunately, many of these patients, despite their renal failure, continue to complain of marked flank discomfort. Nephrectomy in ADPKD is curative of the pain. However, it is a significantly more difficult procedure because of the size of the kidneys and the compromised state of the patient, who is commonly on dialysis or immunosuppression therapy because of renal transplantation. We reported the first case of laparoscopic nephrectomy in a patient with ADPKD in 1996.4 Since that time we have successfully completed this procedure in another eight ADPKD patients. MATERIALS AND METHODS Between March 1995 and April 1998, nine ADPKD patients underwent 11 laparoscopic nephrectomies; seven patients underwent a unilateral nephrectomy, and two patients underwent a staged bilateral nephrectomy (Table 1).
American Journal of Kidney Diseases, Vol 35, No 4 (April), 2000: pp 720-725
LAPAROSCOPIC NEPHRECTOMY IN ADPKD AND ESRD Table 1. Patient Demographics Laparoscopic Nephrectomy
No. of patients/procedures Sex (M/F) Mean age (y) Side Right Left Staged bilateral Presentation Pain HTN UTI/stone Abdominal mass Renal failure GI symptoms (early satiety) Previous surgical intervention
9/11 5/4 53 (45-73) 2 5 2 9 (100%) 8 (89%) 3 (33%) 9 (100%) 7 (78%)* 2 (22%) Open cyst reduction (3) Percutaneous cyst drainage (1)†
*Two patients had a renal transplant before laparoscopic nephrectomy. †Percutaneous cyst drainage was performed 1 month before laparoscopic nephrectomy.
Ten procedures were approached transperitoneally, and one nephrectomy was performed through a retroperitoneal approach. The latter was in a patient with a history of an abdominal hernia repair with Marlex mesh. All patients complained of flank or abdominal pain, but only four patients were regularly using oral narcotic analgesics (Vicodin, Knoll Pharmaceuticals, Mt Olive, NJ; Dilaudid, Knoll; Tylox, Ortho McNeil, Raritan, NJ) preoperatively. Eight of the nine patients presented with hypertension, seven of which were managed with oral agents. Other presentations included recurrent urinary tract infections in three patients, nephrolithiasis in two patients, and macroscopic hematuria in one patient. Two patients complained of early satiety and abdominal distension. Three patients underwent open cyst marsupialization before nephrectomy (in 1960, 1988, and 1992, respectively); earlier in our experience (1996), one patient underwent percutaneous drainage of large cysts 1 month before nephrectomy to reduce the size of the kidneys in preparation for the laparoscopic nephrectomy. Seven patients were on long-term hemodialysis, and two patients had undergone a cadaveric renal transplantation before nephrectomy. Of the latter, one patient underwent transplantation 6 years before nephrectomy, and the other patient underwent transplantation 2 years before the second nephrectomy. Overall, these patients had a 1- to 12-month history of end-stage renal failure before nephrectomy.
Current Operative Technique for Laparoscopic Nephrectomy Our preferred approach is transperitoneal, as was done in 10 of the 11 nephrectomies. A transumbilical pneumoperito-
721
neum is created with the patient in the supine position to avoid injury to the massively enlarged kidneys. The patient is then repositioned and three 12-mm ports and two 5-mm ports are inserted. After medial mobilization of the colon, the anterior surface of the kidney is cleared of Gerota’s fascia and perirenal fat. In situ aspiration of the anterior nonhilar cysts is done to reduce the size of the kidney and thereby facilitate further mobilization of the kidney to access the renal vessels. The renal hilum is then dissected, and the renal artery is secured with five laparoscopic clips (9 mm) while the renal vein is occluded with a laparoscopic vascular stapler. The ipsilateral adrenal gland is spared. Dissection is continued along the lower and upper pole of the kidney, additionally draining large cysts. The posterior surface of the kidney is then dissected and cysts along the surface are aspirated or unroofed. The ureter is then divided between two laparoscopic 9-mm clips. Next, an 8 ⫻ 10-inch LapSac (Cook Urological Inc, Spencer, IN) is placed in the abdomen and opened. The kidney is manipulated into the sack and morcellated with either mechanical forceps or an electrical tissue morcellator (Cook Urological Inc, Spencer, IN). In our first three patients, the specimen was retrieved intact via a 7- to 12-cm ipsilateral lower quadrant incision. In one patient with multiple giant hepatic cysts, laparoscopic marsupialization of the hepatic cysts was performed in the supine position first. The patient was then repositioned to the lateral position for the laparoscopic nephrectomy. For follow-up evaluation, patients were mailed a questionnaire assessing their postoperative pain, quality of life, and current medical condition. In addition, all patients underwent a phone call evaluation to assess the same parameters. Pain was assessed using a standardized pain analogue scale (0 to 10), with 0 indicating no pain and 10 indicating the worst pain.
RESULTS
Overall, the mean operating room (OR) time was 6.3 hours (Table 2), with a mean estimated blood loss (EBL) of 153 mL. This excludes the single patient who underwent simultaneous laparoscopic nephrectomy and hepatic cyst marsupialization. In that patient, OR time was 6.8 hours and EBL was 150 mL. For the intact removal group (3 cases), OR time and EBL averaged 7.0 hours and 300 mL, respectively. Likewise, for the morcellated group (8 cases), the mean OR time and EBL were 6.1 hours and 132 mL, respectively. The overall average specimen weight was 769 g, with a range of 132 to 2,200 g. This wide range was dependent on the number of cysts drained during the procedure and whether the specimen was removed intact or entrapped and morcellated. For intact removal, the average specimen weighed 1,382 g, whereas the morcellated specimens averaged only 539 g. From experience, it has now become our practice to reduce
722
DUNN ET AL Table 2. Operative Data
Approach: Transperitoneal Retroperitoneal OR time (h) EBL (mL) Specimen weight (g)
Laparoscopic Nephrectomy (11 procedures)
Intact Removal (3 procedures)
Morcellated (8 procedures)
10 procedures 1 procedure 6.3 (3.4-8.8)* 153 (50-500)* 769 (132-2,200)
2 1 6.3 and 7.7* 100 and 500* 1,382 (750-2200)
8 0 6.1 (3.4-8.8) 132 (50-200) 539 (132-985)†
*Excludes one patient in whom hepatic cysts were also unroofed at the time of the nephrectomy, which resulted in a total operative time of 6.8 hours and EBL of 150 mL. †Does not include cyst fluid, which is aspirated at the time of morcellation.
the specimen size through aspiration of cyst fluid in situ, so that the kidney can be entrapped, morcellated, and evacuated through one of the 12-mm port sites, thereby precluding the need to make a sizable incision. The postoperative hospital course is illustrated in Table 3. For the whole group, average time to oral intake was 19 hours, and postoperative parenteral analgesia requirement averaged 33 mgMSEq. (equivalents of morphine sulfate: 1 mgMS ⫽ 10 mg meperidine). Time to oral intake for the intact removal versus the morcellated group was 20 hours and 19 hours, respectively. Average analgesic requirement in the intact removal group was 42 mg and 29 mg in the morcellated group. The average hospital stay was 3 days and was essentially similar for the patients whose specimens were removed intact (3.7 days) or morcellated (3.3 days). Two intraoperative complications occurred. In one patient, a small vena cavotomy occurred, which was controlled laparoscopically with the EndoStitch (Ethicon Endosurgery, Cincinnati,
OH) suturing device. The EBL was 500 mL for that patient, and a blood transfusion of 2 units was required in the immediate postoperative period. The other intraoperative complication was splenic cyanosis after mobilizing the superior pole of the kidney near the splenic hilum. An intraoperative general surgery consult was obtained and recommended no further management because there was no hemorrhage. The subsequent postoperative course for that patient was unremarkable; no postoperative imaging was obtained. One patient developed a brachial plexus injury noted immediately postoperatively which has persisted, although mildly improved, 12 months later. One patient developed occlusion of his hemodialysis shunt on the day after surgery which was subsequently revised at an outside hospital closer to the patient’s home. Other complications included pulmonary embolism in one patient, which was managed medically with systemic and then oral anticoagulation. Two of the three patients who had intact removal of their specimens devel-
Table 3. Hospital Course Laparoscopic Nephrectomy (11 procedures)
Oral intake (h) Parenteral analgesia (mgMS equivalent) Hospital stay (d) Complications (total no.)
Pathology
Intact Removal (3 procedures)
Morcellated (8 procedures)
19 (8-36)
20 (8-36)
19 (8-24)
33 mg (5-100) 3 (2-5) 6
42 mg (5-100) 3.7 (3-4) 1 (vena cavotomy) 1 (blood transfusion)
29 mg (5-44) 3.3 (2-5) 1 (pulmonary embolism) 1 (splenic cyanosis) 1 (brachial plexus injury, persistent) 7—benign 1—RCC (papillary)
Benign—10 kidneys RCC (papillary)—1 kidney
1 (occluded dialysis shunt) 3—benign
LAPAROSCOPIC NEPHRECTOMY IN ADPKD AND ESRD
oped postoperative incisional hernias. One patient underwent open surgical repair, and the other has refused any repair because she is asymptomatic. With respect to final pathology, 1 specimen had grade 1, papillary renal cell carcinoma, whereas the remaining 10 specimens were all benign. The former patient ultimately underwent open nephrectomy of the contralateral kidney at an outside institution 7 months after the laparoscopic nephrectomy. This was out of concern for possible tumor in the other kidney, although pathology for that specimen was benign. At 20 months follow-up, this patient has no physical or radiographic sign of tumor recurrence. With a mean follow-up of 31 months, all 9 patients reported complete resolution of their preoperative pain on the side of surgery (0 on a scale of 0-10; Table 4). One patient underwent open removal of the contralateral kidney emergently for hemorrhage approximately 9 months after the original laparoscopic nephrectomy. Five of seven dialysis patients progressed to renal transplantation, 7 to 12 months after laparoscopic nephrectomy. Among eight patients with preoperative hypertension, hypertension was unchanged (taking same medication) in 2 patients (25%), improved in one patient (12.5%) (decreased number of medications), and resolved in two patients (25%) (off all blood pressure medication). Of the two patients who underwent bilateral nephrectomies, the hypertension improved in one and resolved in the other, each only after the second nephrectomy. Three patients (37.5%)
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had worsening of their blood pressure control. Two of these patients required additional medication; the other, who was mildly hypertensive and not on medication preoperatively, needed medication within 6 months after surgery. The one patient without preoperative hypertension remains normotensive. DISCUSSION
Abdominal discomfort and flank pain are found in half to 60% of all patients with ADPKD, necessitating the use of nonsteroidal anti-inflammatory agents and narcotic analgesics.1,5 Additionally, hypertension occurs in 60% of these patients which is usually cyst related. For patients with ESRD and medically refractory flank pain, open nephrectomy is usually the next course of action. However, because of the large size of the kidneys and the high risk of these patients (ie, on dialysis or postrenal transplantation), nephrectomy is associated with high morbidity and mortality rates (12% and 5%, respectively).6,7 In part because of these problems, the nephrectomy rate in ADPKD patients with ESRD decreased from 85% in the early 1970s to only 47% in the late 1980s.8 Laparoscopic nephrectomy was first performed in 1990.9 Since that time, laparoscopic simple nephrectomy has become widely accepted and practiced.10 In addition, larger kidneys have been approached and successfully removed as the indications for laparoscopic nephrectomy have been extended to include patients with renal cell can-
Table 4. Postoperative Follow-Up Laparoscopic Nephrectomy (11 procedures)
Mean follow-up (mo) Time to normal activity* (wk) Pain relief (%)† HTN status Resolved Improved Same Deteriorated Late complications
31 (14-49) 5 (1-12) 100 (8 patients) 2 (25%) 1 (12.5%) 2 (25%) 3 (37.5%) 3
Intact Removal (3 procedures)
Morcellated (8 procedures)
48 (47-49) 3.5 (3-4) 100
25 (14-42) 5 (1-12) 100
1 2 (incisional hernias)
2 1 1 3 1 (brachial nerve palsy, persistent)
*Assessed retrospectively at the time of the questionnaire or phone call evaluation. †Based on a pain analog scale by mailed questionnaire or phone call evaluation on two separate occasions at least 6 months apart.
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cer up to 7 cm.11 Indeed, specimens as large as 1,500 g have been successfully removed.12 Extension of laparoscopic nephrectomy to patients with ADPKD was first reported by Elashry and colleagues4 in 1995 with the laparoscopic intact removal of a 2,200-g specimen from a 15-cm incision.4 Operative time for this patient was 487 minutes, hospital stay was 3 days, and return to normal activity occurred in 4 weeks. Unfortunately, this patient also developed a postoperative incisional hernia at the site of intact removal. Since our initial report, we have changed our technique in one important aspect. We have abandoned intact removal in exchange for widespread cyst drainage, entrapment, and morcellation. We believe this should eliminate any further problems of wound hernia formation. In comparing our experience with the initial three cases of intact removal with the subsequent eight cases of morcellation, there was a reduction in the blood loss, operative time, and postoperative use of parenteral analgesics in the morcellation group. This difference is likely a reflection of our increased experience, the time saved by not having to close the 7- to 12-cm incision, and the decreased size of the operative wounds. This approach should also limit the wound-related problems, which accounted for almost half of our patients’ postoperative complications. The occurrence of a brachial plexus injury reinforces the importance of proper patient positioning and padding. We routinely pad the axillary region as well as all extremities and pressure points. The arm is never extended more than 90° at the shoulder. Likewise, the patient is well secured to the table with straps to maintain positioning during table movements. Close attention must be paid to arm placement not only before surgery but also during surgery to ensure that shifts in body position have not occurred during the course of the operation. This is especially important in prolonged laparoscopic procedures. Laparoscopic procedures, certainly in their early stages, require more operative time to complete than their open counterparts. This is especially true in ADPKD because of the huge renal size, surrounding fibrosis, and proximity to several vital structures. This technical difficulty is reflected in the longer average operative times (6.3 hours) as compared with our more recent
DUNN ET AL
laparoscopic radical nephrectomy series, which is considerably shorter (4.5 hours).12 However, as shown in the laparoscopic versus open radical nephrectomy literature, this increased time expenditure is counterbalanced by a decrease in analgesic use, hospital stay, and convalescence.13,14 The problem of operating room efficiency, we believe, will improve as more urologists become adept at laparoscopic procedures. Also, the advent of hand-assisted laparoscopy will allow these procedures to be done more quickly by a larger number of urologists. Indeed, with the hand-assisted approach, several centers have now reported operating room times for radical nephrectomy in a range equivalent to open surgery. Preliminarily, our early experience concurs that the hand-assisted technique appears to facilitate the dissection and removal of these large kidneys. Recent literature has documented the problems experienced by ADPKD patients after transplantation. In one series, 47% of those ADPKD patients with a pretransplantation history of renal cyst–derived maladies (ie, pain, infection, hemorrhage) experienced cyst related problems posttransplantation; among those without pretransplantation cyst-related problems, these difficulties arose in 39% during the posttransplantation follow-up period. It appeared that nephrectomy before transplantation was of some benefit. Indeed, the 5-year graft survival and 5-year patient survival were improved by 19% and 18%, respectively, among those ADPKD patients undergoing pretransplantation nephrectomy.15 Hence, a case can be made for proceeding with a nephrectomy before transplantation for those patients with a history of unilateral cyst-related signs and symptoms. Given the effectiveness and excellent convalescence associated with the laparoscopic approach, we believe more patients with ADPKD and ESRD may become candidates for nephrectomy. CONCLUSION
Laparoscopic nephrectomy with morcellation for ADPKD can be accomplished successfully and safely. This technique offers ADPKD patients the potential benefits of minimal intraoperative blood loss, minimal postoperative pain, a brief hospital stay, and rapid convalescence while avoiding the typically large incision associated
LAPAROSCOPIC NEPHRECTOMY IN ADPKD AND ESRD
with this procedure when done by either open surgery or laparoscopic intact removal. REFERENCES 1. Gabow PA: Autosomal dominant polycystic kidney disease. N Engl J Med 329:332-342,1993 2. Bell PE, Hossach KE, Gabow PA, Durr JA, Johnson AM, Schrier RW: Hypertension in autosomal dominant polycystic kidney disease. Kidney Int 34:683-690, 1988 3. Parfrey PS, Bear JC, Morgan J, Carmer BC, McManamon PJ, Gault MH, Churchill DN, Singh M, Hewitt R, Somlo S, Reeders ST: The diagnosis and prognosis of autosomal dominant polycystic kidney disease. N Engl J Med 323:1085-1090, 1990 4. Elashry OM, Nakada SY, Wolf JS, McDougall EM, Clayman RV: Laparoscopy for adult polycystic kidney disease: A promising alternative. Am J Kidney Dis 27:224-233, 1996 5. Milutinovic J, Fialkow PJ, Agodoa LY, Phillips LA, Rudd TG, Sutherland S: Clinical manifestations of autosomal dominant polycystic kidney disease in patients older than 50 years. Am J Kidney Dis 15:237-243, 1990 6. Mendelssohn DC, Harding ME, Cardella CJ, Cook GT, Uldall PR: Management of end-stage autosomal dominant polycystic kidney disease with hemodialysis and transplantation. Clin Nephrol 30:315-319, 1988 7. Florjin KW, Chang PC, van der Woulde FJ, van Bockel JH, van Saase JLCM: Long-term cardiovascular morbidity and mortality in autosomal dominant polycystic kidney
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disease patients after renal transplantation. Transplantation 57:73-81, 1994 8. Ho-Hsieh H, Novick AC, Steinmuller D, Streem SB, Buszta C, Goomstic M: Renal transplantation for end stage polycystic kidney disease. Urology 30:322-326,1987 9. Clayman RV, Kavoussi LR, Soper NJ, Dierks SM, Meretyk S, Darcy MD, Long SR, Roemer FD, Pingleton ED, Thomson PG: Laparoscopic nephrectomy. N Engl J Med 324:1370-1372, 1991 (letter) 10. Eraky I, El-Kappany H, Shamaa MA, Ghoneim MA: Laparoscopic nephrectomy: an established routine procedure. J Endourology 8:275-279, 1994 11. Ono Y, Katoh N, Kinukawa T, Matsuura O, Ohshima S: Laparoscopic radical nephrectomy: The Nagoya experience. J Urol 158:719-724, 1997 12. Dunn MD, Portis AJ, Shalhav AL, Heidorn C, Elbahnasy AM, McDougall EM, Clayman RV: Laparoscopic vs. open radical nephrectomy: The Washington University experience. J Urol 161:S166, 1999 (abstr; suppl 4) 13. McDougall EM, Clayman RV, Elashry OM: Laparoscopic radical nephrectomy for renal tumor: The Washington University experience. J Urol 155:1180-1185, 1996 14. Ono Y, Kinukawa, T, Hattori R, Yamada S, Nishiyama N, Mizutani K, Ohshima S: Laparoscopic radical nephrectomy for renal cell carcinoma: A five year experience. Urology 53:280-286, 1999 15. Brazda E, Ofner D, Riedmann B, Spechtenhauser B, Margreiter R: The effect of nephrectomy on the outcome of renal transplantation in patients with polycystic kidney disease. Ann Transplant 1:15-18, 1996