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Keywords:

  • autosomal-dominant polycystic kidney disease;
  • laparoscopic nephrectomy;
  • polycystic kidneys

Abstract

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. PATIENTS AND METHODS
  5. RESULTS
  6. DISCUSSION
  7. CONFLICT OF INTEREST
  8. REFERENCES

OBJECTIVE

To present our experience with bilateral laparoscopic nephrectomy (BLN) for symptomatic autosomal-dominant polycystic kidney disease (ADPKD), as surgical management of massively enlarged polycystic kidneys can be a daunting task.

PATIENTS AND METHODS

The study was a retrospective chart review of all patients undergoing BLN for ADPKD. Patient demographics, indications for the procedure, perioperative data, and pathological data were analysed.

RESULTS

In all, 12 patients underwent BLN at our institution; eight were performed before transplant, three after transplant, and one with a concomitant kidney transplant. Indications for surgery included abdominal pain, fullness and early satiety, recurrent urinary tract infections, and need for space for future transplant. The mean patient age was 49.6 years, with a body mass index of 27.0 kg/m2. The mean operative duration was 214 min, estimated blood loss was 169 mL, and the hospital stay was 4 days. There were no conversions to open surgery. The mean (range) pathological kidney mass was 2243 (656–4200) g on the left and 2379 (789–5042) g on the right. No patients with a previous renal transplant had deterioration in postoperative renal function. There was one minor intraoperative complication, one postoperative complication, and one patient with preoperative anaemia required a blood transfusion.

CONCLUSIONS

Symptomatic patients with ADPKD due to massively enlarged kidneys should be considered for BLN when performed by an experienced laparoscopic surgeon. This includes patients with an existing renal allograft and candidates for concomitant transplantation. The approach should be tailored to avoid injury to adjacent structures secondary to displacement from the mass effect of these kidneys.


Abbreviations
(B)LN

(bilateral) laparoscopic nephrectomy

ADPKD

autosomal-dominant polycystic kidney disease

ESRD

end-stage renal disease

BMI

body mass index

EBL

estimated blood loss.

INTRODUCTION

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. PATIENTS AND METHODS
  5. RESULTS
  6. DISCUSSION
  7. CONFLICT OF INTEREST
  8. REFERENCES

Autosomal-dominant polycystic disease (ADPKD) is responsible for 10% of patients developing end-stage renal disease (ESRD) in the USA. Almost half of patients afflicted will develop ESRD by the age of 60 years [1]. These nonfunctional kidneys can be massively enlarged and cause symptoms severe enough to necessitate nephrectomy. Symptoms can include infection, haematuria, intracystic haemorrhage, abdominal pain, early satiety and hypertension. These kidneys can also occupy so much space that there remains no room for potential kidney transplantation. The rate of open nephrectomy for these indications has decreased over the past decades secondary to the significant associated morbidity [2]. Elashry et al. [3] reported the first unilateral laparoscopic nephrectomy (LN) for ADPKD in 1996, thus popularizing the approach to this problem. However, unilateral nephrectomy is often insufficient to alleviate the symptoms, and can be a difficult option when the other diseased kidney remains in situ and can continue to enlarge. We present our experience of bilateral LN (BLN) in the setting of ADPKD and ESRD. We also present the first published case of BLN for giant polycystic kidneys with concomitant renal transplant.

PATIENTS AND METHODS

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. PATIENTS AND METHODS
  5. RESULTS
  6. DISCUSSION
  7. CONFLICT OF INTEREST
  8. REFERENCES

With Institutional Review Board approval, we retrospectively reviewed the charts of 12 patients who had undergone BLN for ADPKD. Patient demographics including age, body mass index (BMI), gender as well as indications for the procedure were collected. Intraoperative and postoperative data including operative duration, estimated blood loss (EBL), hospital stay, pathological kidney mass and complications were reviewed.

Surgical technique

All patients underwent preoperative imaging including CT or MRI. After administering general anaesthesia and urethral catheter placement, the patient is positioned supine without flexion of the bed and secured with cloth tape to the table to allow secure rotation of the table for each nephrectomy. A 7-cm low midline incision is made to allow for safe entry into the abdomen and to allow for GelPort® (Applied Medical, Rancho Santa Margarita, CA, USA) placement. Insufflation is performed through a 12-mm blunt port placed within the device. The abdomen is visualized through a 10-mm 30° lens before placement of the working ports, which are placed under direct visualization of the abdominal cavity to help prevent damage to the abdominal viscera upon initial access. The working ports are placed as shown in Fig. 1. The table is rotated away from the side of dissection to allow the bowel to fall contralaterally. The lateral line of Toldt is dissected with ultrasonic shears to allow access to the retroperitoneum. On the right side the duodenum is Kocherized to allow visualization of the vena cava and renal hilum. With the bowel reflected medially, the ureter is bluntly dissected and retracted laterally to allow access to the lower pole of the kidney. On the left side the gonadal vein is retracted in a package with the ureter to allow for easier identification of the renal vein, while on the right it is avoided in order to avoid inadvertent avulsion from the vena cava. Careful dissection is performed toward the renal hilum, with lumbar veins controlled with ultrasonic shears or an endovascular stapling device depending on size. An assistant’s hand is used through the GelPort® when manual retraction of the bowel is required to allow adequate hilar exposure of the largest specimens. The upper pole is dissected within Gerota’s fascia, allowing the adrenal gland to be retracted medially preventing inadvertent adrenalectomy. The lateral attachments are kept intact to help the kidney from falling medially during hilar dissection. The renal hilum is then identified, and the endovascular gastrointestinal anastomosis (GIA) stapling device is used to divide the artery and then the vein. The lateral attachments are freed, with the ureter divided between clips (the gonadal vein on the left is controlled in a similar manner). Manual inspection confirms all attachments have been freed, and then the kidney is removed longitudinally after the midline incision is extended 2–3 cm cranially. Care is taken to minimize cyst rupture during dissection and retraction. The kidney is removed to allow a greater working space for the contralateral dissection. The fascia is closed back to the initial size (7 cm), the GelPort® is replaced, and the contralateral nephrectomy is then performed. The fascia is re-opened to allow for specimen retrieval and then partially closed before re-insufflating the abdomen, irrigating with saline and inspecting for haemostasis. The 12 mm ports are all closed with zero polyglycolic acid suture, and the extraction site closed with 1/0 polyglycolic acid suture. The skin is closed with a subcuticular suture.

image

Figure 1. (a) Port placement for BLN and (b) after closure of incisions. A 10-mm port (the camera port) is placed at the midline midway between the umbilicus and the xiphoid, with a 5-mm port placed subxiphoid to assist with liver retraction on the right. A 10-mm port is placed along the midclavicular line at the level of the umbilicus on the left side, while a 5-mm port is placed symmetrically on the right. A 5-mm port is placed along the midclavicular line at the costal margin on the left, while a 10-mm port is placed symmetrically on the right.

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RESULTS

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. PATIENTS AND METHODS
  5. RESULTS
  6. DISCUSSION
  7. CONFLICT OF INTEREST
  8. REFERENCES

In all, 12 patients underwent BLN (Table 1) and all had ESRD; eight were performed before transplant and three after renal transplant. The remaining patient had BLN with concomitant living-related kidney transplantation through the same midline extraction site. Indications for BLN were not exclusive and included abdominal pain refractory to medical management in eight patients; fullness and early satiety in two; need to create space in the pelvis for future renal transplant in one; and recurrent UTIs involving renal cysts in two.

Table 1.  Data of the 12 patients undergoing BLN for large polycystic kidneys
PatientIndicationAge, yearsBMI, kg/m2Surgical duration, minEBL, mLHospital stay, daysKidney mass, gBLN complications
LeftRightDuringAfter
  1. PE, pulmonary embolus.

1Pain3830.0170 75632002600NoneNone
2Pain4425.9225100425002100NoneNone
3Pain5728.0240100224442412NoneNone
4Pain, early satiety4129.3208200326043375NoneNone
5Fullness, early satiety5520.5150200212351388NoneNone
6Pain, recurrent UTI4431.4195250618911894NoneSmall PE
7Pain5222.2180350442005042NoneNone
8Need for allograft space5524.7390200621252405NoneNone
9Recurrent UTI6423.11201002 656 789NoneNone
10Pain4127.1145 50510331071NoneNone
11Pain5029.7333300624102659Duodenal serosal tearNone
12Fullness5431.7210100226212809NoneNone

The mean (range) patient age was 49.6 (38–64 year) years, with a BMI of 27.0 (22.2–31.4 kg/m2) kg/m2. The mean surgical time was 214 (120–390) min, the mean EBL was 169 (50–350) mL, and mean hospital stay was 4.2 (2–6) days. The mean pathological kidney mass was 2243 g on the left, and 2379 g on the right, including one patient who had left and right kidney masses of 4200 g and 5042 g, respectively (Fig. 2a,b).

image

Figure 2. (a) Coronal CT view of a 52-year-old man before hand-assisted BLN and (b) the specimens removed by hand-assisted BLN. The pathological weights of the left and right kidney were 4200 g and 5042 g, respectively.

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All cases were successfully completed laparoscopically with no conversion to open surgery. There was one intraoperative complication, a serosal duodenal tear was recognized and repaired laparoscopically without further sequelae. There was one postoperative complication, a subacute small pulmonary embolus, which was discovered 4 weeks after surgery when the patient complained of chest pain and shortness of breath. She was started on anticoagulation therapy and her remaining recovery was uneventful. One patient with a preoperative haemoglobin of 9.7 g/dL and intraoperative blood loss of 200 mL received 2 units of packed red blood cells after surgery, with no other patient requiring transfusion.

DISCUSSION

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. PATIENTS AND METHODS
  5. RESULTS
  6. DISCUSSION
  7. CONFLICT OF INTEREST
  8. REFERENCES

ADPKD affects an estimated 500 000 people in the USA. Hypertension can occur in 60% of these patients before the onset of renal insufficiency, and in 80% with renal failure [4]. About 60% of patients have pain from the enlarged kidneys. They may also develop cystic haemorrhage and anaemia, infection or urolithiasis (20%). Half of these patients have gross or microscopic haematuria. Approximately 45% of patients with ADPKD will have ESRD by the age of 60 years. The disease is responsible for causing 10% of all cases of ESRD. Extrarenal manifestations include cysts in other organs (liver, ovary, pancreas, spleen and CNS), mitral valve prolapse, intracranial berry aneurysm, and colon diverticula [5].

Most patients, even with ESRD, are asymptomatic. However, there is a small percentage of patients that develop massively enlarged kidneys that require treatment of symptoms. Symptoms that occur because of the enlarged kidneys can include pain, early satiety, gastroesophageal reflux, hypertension, infection, haematuria, renal cystic haemorrhage, urinary tract obstruction, and urolithiasis. Surgical treatment for these kidneys has generally been reserved for patients who have failed conservative medical management, or to establish space for renal transplant.

Traditional open bilateral nephrectomy has been associated with significant morbidity and because the symptoms often prompting the treatment are vague and cannot be localized, the frequency of this procedure has decreased significantly in recent decades [6]. Elashry et al. [3] described the first LN for a polycystic kidney in 1996, and since then many institutions have performed this procedure showing decreased morbidity compared with the open approach [7]. Often these symptomatic patients have diffuse symptoms and bilateral massively enlarged kidneys necessitating bilateral nephrectomy. Gill et al. [8] described the first series of synchronous BLN with intact specimen retrieval utilizing the retroperitoneal approach in 2001 and since then only one other institution has published a series involving more than four patients demonstrating their technique.

Lipke et al. [9] described their successful hand-assisted BLN experience in 14 patients, with four patients converted to the open approach mainly secondary to size. A transperitoneal approach was used with a peri-umbilical Gelport® used for hand assistance. The authors concluded that large kidneys of >3500 mL might be better treated by open nephrectomy given their high rate of conversion in these patients in their series.

Whitten et al. [10] described their technique of vacuum curettage to morcellate and aspirate the kidney with good results. We chose intact specimen retrieval in the present series for two reasons. The first was that active spillage of cyst contents has been associated with peritonitis-like symptoms in a few patients with subsequent ileus, and the second is the small but plausible chance that the kidney might harbour malignancy [11,12].

The immense size of these kidneys and often surrounding inflammation make this procedure particularly difficult, with a potentially higher complication rate compared with standard LN. The large kidneys can often obstruct the view of surrounding structures and can displace them increasing the risk of disorientation. An institutional review of unilateral LN for ADPKD was performed by Bendavid et al. [13], in which a suction aspiration device was used to disrupt and aspirate the cysts for volume reduction and ease access to the hilum. There was an 18% conversion to open surgery for different reasons, including trocar injury to the colon, intraparenchymal bleeding during cyst aspiration, and a caval injury during cyst aspiration adjacent and adherent to the vena cava.

Our technique was developed to help minimize these potential pitfalls. Our port placement was developed based on the technique developed with laparoscopic donor nephrectomy at our institution. An infra-umbilical incision was used for GelPort® placement. Ports were placed for pure laparoscopic dissection, with an additional port placed through the GelPort® for retraction. At the conclusion of the dissection, the specimen was removed through the GelPort®, with most patients reporting minimal pain postoperatively. During BLN for large polycystic kidneys, a 7-cm low midline incision is also made for GelPort® placement as initial access, with insufflation subsequently performed through a blunt trocar placed within the port. The remaining ports are placed are under direct visualization within the abdomen to help prevent visceral injury.

The surgery is performed primarily utilizing pure laparoscopic techniques secondary to the lack of space in the abdomen; however, during BLN for massively enlarged kidneys, an assistant’s hand through the GelPort® can help with retraction of the bowel during laparoscopic dissection to allow for optimal exposure of the hilum medially. This technique probably helped prevent conversion during BLN for the largest kidneys in our series (4200 g and 5042 g). The reason pure laparoscopic dissection is chosen over a standard hand-assist technique by the surgeon is because of the limited space available for dissection, as well as the potentially decreased field of view when the hand is placed in the field. When the kidneys are extracted the cysts are kept intact as much as possible to help prevent the theoretical risk of a chemical peritonitis. Each surgery was performed with the goal initially to create space by removing the ‘easier’ kidney to create a greater space for safe dissection of the more ‘challenging’ and often larger kidney.

In the present series, as with other published series, there was no deterioration in allograft function in the three patients with previous renal transplant [9]. Ismail et al. [14] described their experience with hand-assisted BLN and then staged transplantation at a later setting with good results. In their discussion an alternative surgical approach was proposed of same day BLN followed by renal transplant. This was performed successfully in one of the present patients with a total operative duration of 350 min and EBL of 450 mL. To our knowledge, this is the first published case to date. Her most recent serum creatinine level is 1.1 g/dL.

A few unique considerations need to be given to this subset of patients after surgery. As described previously, some can have peritonitis-like symptoms with subsequent prolonged ileus, presumably secondary to spillage of cyst contents that often preoperatively are presumed to be the cause of recurrent infections. The possibility of adrenal insufficiency also needs to be considered in an ill patient postoperatively as the massive size of these kidneys can make this surgical dissection indistinct.

Limitations of this study are the few patients, and the lack of a comparative group undergoing open bilateral nephrectomy. The potential morbidity associated with the open approach makes it very difficult to offer to a patient when the laparoscopic approach can be considered first. Considerable experience with standard LN is paramount to optimizing patient outcome. It needs to be emphasized that although no conversions took place in the present series, extreme caution needs to be taken when embarking on these procedures due to the potential risks, with every patient counselled preoperatively as to the risk of conversion to open surgery if deemed necessary.

In conclusion, when indicated, symptomatic patients with ADPKD can be considered for BLN to reduce morbidity, but only when performed by an experienced laparoscopic surgeon. Patients who are transplant candidates can be considered for a concomitant procedure, but transplantation should be dependent on successful BLN with minimal blood loss and normal intraoperative blood pressure. The described approach for port placement can help minimize injury to the abdominal viscera, which is often displaced in this setting, and can help optimize retraction during dissection of the largest (>4000 g) of kidneys. Cyst decortication should be minimized to help prevent postoperative peritonitis and ileus. The surgeon must be aware of the unique risks associated with this surgery, and be prepared to convert to open surgery whenever necessary.

REFERENCES

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. PATIENTS AND METHODS
  5. RESULTS
  6. DISCUSSION
  7. CONFLICT OF INTEREST
  8. REFERENCES