Cystic renal cell carcinoma arising from multilocular cystic nephroma of the same kidney

Multilocular cystic nephroma is an uncommon benign entity grouped among the cystic non-genetic diseases. It is characterized by variable-sized, non-communicating cysts separated by irregular thin walled septa. Though multilocular cystic nephroma is usually considered a benign lesion, malignant changes in the cysts should not be overlooked.

The parapelvic renal cyst. A rare aetiology of blood hypertension in children

Parapelvic renal cysts are uncommon in children. We report a case occurring in a 2-year-old girl, diagnosed during follow-up for blood hypertension. The cyst measured 8 cm in length. There was associated hydronephrosis, due to obstruction of the renal pelvis. Surgical resection was performed. Normotension returned within 3 months, and the obstruction disappeared. A renovascular mechanism can be evoked to explain hypertension.

Laparoscopic Removal of Renal Cysts in Patients With ADPKD as an Alternative Method of Treatment and Patient Preparation for Kidney Transplantation: Preliminary Results

BACKGROUND

The most frequent genetic disease of the kidneys occurring in 1 of 1000 inhabitants is autosomal-dominant polycystic kidney disease (ADPKD). Growing renal cysts compress the kidney resulting in damage to parenchyma and functional disorders. Around 10% of these patients are dialyzed due to terminal renal insufficiency. With the advent of laparoscopic techniques, the idea of laparoscopic excision of cysts seemed a tempting alternative to nephrectomy. We assessed the preliminary results of laparoscopic treatment of polycystic kidneys compared with open nephrectomy for patients with ADPKD.

MATERIALS AND METHODS

Thirty ADPKD patients were treated between 2000 and 2004. Eleven procedures in five men and six women of mean age 51 years included laparoscopic cyst excisions. In the remaining 19 patients (six men and 13 women) of mean age 54 years, nephrectomy was done. Indications for surgery included pain due to compression by large cysts and cyst contamination. Patients after nephrectomy were prepared for renal transplantation when necessary.

RESULTS

Laparoscopic polycyst removal produced better effects than nephrectomy. Mean operative time was significantly shorter (86 minutes for cyst removal vs 108 minutes for nephrectomy; P < .05). Postoperative pain measured with the VAS scale was reduced in patients after laparoscopy. Hospital stay was shorter (5 vs 9 days), as well as time to recovery. Other benefits of laparoscopic cyst removal included maintained urination in the patient and no need for erythropoietin substitution, as well as reduced risk of cyst contamination. When eligible for renal transplantation, patients after laparoscopic polycyst removal have smaller kidneys that do not interfere with the graft and the risk of infection during immunosuppression seems lower.

CONCLUSION

Although larger series of patients are required in patients with ADPKD, laparoscopic polycyst removal seemed superior to early nephrectomy.

Treatment of symptomatic simple renal cysts by percutaneous aspiration and ethanol sclerotherapy

OBJECTIVE

To report our experience with the use of 95% ethanol as sclerotherapy for symptomatic simple renal cysts.

PATIENTS AND METHODS

Sixty patients with 64 symptomatic simple renal cysts were treated by ultrasonography (US)-guided percutaneous aspiration and injection of 95% ethanol (31 men and 29 women, mean age 46 years, SD 22). The main presentation was renal pain in 34 patients, renal mass in nine, hypertension in 11 and haematuria in six; 24 cysts were on the right, 32 on the left and four bilateral. Patients were evaluated after 1 month and then every 6 months by clinical assessment, US and intravenous urography. Success was defined as complete when there was total ablation of the cyst and partial when there was a recurrence of less than half the original cyst volume with the resolution of symptoms. Failure was defined as the recurrence of more than half of cyst volume and/or persistent symptoms.

RESULTS

After aspiration and ethanol sclerotherapy, there was microscopic haematuria in two patients and low-grade fever (<38.3 degrees C) in two, but no major complications. During a mean (range) follow-up of 19 (14-40) months there was complete cyst ablation in 54 cysts and partial resolution in 10. Pain disappeared or was much improved in all patients. After cyst ablation hypertension was well controlled with no medication in all 11 hypertensive patients and haematuria disappeared in all six affected patients.

CONCLUSIONS

Ethanol sclerotherapy for symptomatic simple renal cysts is simple, minimally invasive and highly effective. We recommend it as the first therapeutic option in these patients.

A complicated case of bilateral cystic nephroma in a 16-month-old boy

We describe a case of a progressive bilateral cystic nephroma (BCN) in a child undergoing a multistaged surgical procedure. After partial resection of the left sided tumor, a progress occurred on that side and the left kidney had to be removed 10 weeks later. After 35 months a tumor progression was observed on the right side together with an ureteral obstruction leading to a decreased renal function. In a third operation a complete tumor resection on the right side was achieved through longitudinal partial nephrectomy, reconstruction of the renal pelvis, and reanastomosis of the reconstructed pelvis and ureter. The patient showed no evidence of the disease at 28 months of follow-up. The presented case provides an evidence that in BCN a tumor progress may occur after multistaged surgical approaches. A single-staged complete tumor resection with renal salvage techniques seems indicated.

CYSTIC RENAL CELL CARCINOMAS IN ADULTS. IS PREOPERATIVE RECOGNITION OF MULTILOCULAR CYSTIC RENAL CELL CARCINOMA POSSIBLE?

PURPOSES

We correlated clinicopathological and imaging features of multilocular cystic renal cell carcinoma (MCRCC) to propose preoperative criteria for therapeutic modalities.

MATERIALS AND METHODS

A total of 24 RCCs with a chiefly cystic component were identified from 1993 to 2002. In each case histological slides and available imaging studies were retrieved. Two tumor groups were defined, namely MCRCC and clear RCC with cystic change (CRCC) by intrinsic growth or necrotic degeneration. Radiological correlation using computerized tomography and magnetic resonance imaging was performed considering criteria such as an expansile nodule, cyst wall thickness and septa.

RESULTS

On imaging MCRCC presented as a multilocular cystic mass lacking an expansile nodule, and with regular thin cyst wall and septa. On pathological study MCRCC presented as complex, multilocular cystic carcinoma with septa covered by low nuclear grade clear renal tumor cells without a grossly expansile nodule. They were staged pT1 with a free clinical course. In contrast, CRCC was identified on imaging with an expansile nodule (5 mm or greater), thick, irregular cyst wall and septa. On pathological study CRCC was characterized by a grossly expansile nodule in the septa and/or cyst wall. Nuclear grade and TNM stage were higher in CRCC.

CONCLUSIONS

Preoperative recognition of MCRCC is possible using strict computerized tomography and/or magnetic resonance imaging criteria. The current study confirms the low malignant potential of MCRCC. Nephron sparing surgery should be proposed when MCRCC is suspected.

[Retroperitoneal laparoscopic treatment of parapelvic renal cysts: report of 5 cases]

OBJECTIVES

Renal cysts of the sinuses or parapelvic cysts constitute a rare form of renal cyst, usually associated with low back pain. Symptomatic forms may be treated by percutaneous aspiration, but the treatment of these cysts has changed considerably over recent years due to the proximity of the renal hilum. Percutaneous treatment is now contraindicated due to its high complication rate, and open surgery is an invasive technique. Laparoscopy appears to be the most appropriate and most effective solution.

PATIENTS AND METHODS

The authors report five cases of parapelvic renal cysts all presenting with renal colic and diagnosed by ultrasound, and confirmed by CT in three cases. Treatment consisted of retroperitoneal laparoscopy using four trocars allowing cyst resection with no intraoperative complications or conversion.

RESULTS

The mean operating time was 55 minutes (range: 40 to 70 minutes). The postoperative course was uneventful and all patients were discharged on postoperative D1 or D2. No recurrence was observed after a mean follow-up of 6 months (range: 3 to 15 months).

CONCLUSION

Retroperitoneal laparoscopic treatment of parapelvic renal cysts is an effective approach, with a low morbidity and less postoperative pain, a short convalescence period and good cosmetic results.

Laparoscopic renal surgery: Ramathibodi Hospital experience

OBJECTIVE

To report the authors' early experience of laparoscopic renal surgery for benign and malignant renal conditions.

MATERIAL AND METHOD

Laparoscopic renal surgery was performed on 24 patients with benign and malignant renal conditions between July 2004 and February 2005. The patient characteristics and perioperative data including operative time, blood loss, analgesic requirement, complications, duration of postoperative drain removal, length of hospital stay, and duration to return to normal activity were all recorded.

RESULTS

Laparoscopic simple nephrectomy was performed in 15 patients with nonfunctioning benign renal conditions. Three operations of hand-assisted laparoscopic radical nephrectomy and one of partial nephrectomy were performed for large and small renal cell carcinoma, respectively. Transitional cell carcinomas were managed by retroperitoneoscopic nephrectomy or hand-assisted approach in 3 cases. For a case of severe inflammatory renal condition, hand-assisted approach was used for treatment. Laparoscopic renal cyst decortication was performed in one case. In the laparoscopic simple nephrectomy group, the mean operative time was 126 +/- 38.3 minutes. The median (range) estimated blood loss was 100 (50-500) mL, and one patient required conversion to open surgery because of renal vein injury. In three cases of hand-assisted laparoscopic radical nephrectomy, the operation time was 315, 325 and 150 minutes and the operative blood loss was 500, 1000 and 200 ml, respectively. In cases of hand-assisted laparoscopic partial nephrectomy, the operation time and the operative blood loss were 220 minutes and 350 ml, respectively. In three cases of transitional cell carcinoma, the operation time was 120, 140 and 150 minutes and the operative blood loss was 100, 150 and 150 ml. The surgical margins of all resected specimens for malignant tumors were negative and no major complication was recorded Simple renal cyst decortication was successfully performed within 90 minutes of operation time and bleeding 50 ml. In cases of severe inflammatory renal condition performed by hand-assisted approach, the operative time was 250 minutes and the operative blood loss was 250 ml.

CONCLUSION

Laparoscopic renal surgery is a safe and efficacious approach for resection of benign nonfunctioning kidneys and malignant renal tumors.

Bilateral Laparoscopic Radical Nephrectomy for Renal Tumors in Patients with Acquired Cystic Kidney Disease

PURPOSE

We describe our experience with simultaneous bilateral laparoscopic radical nephrectomy performed in patients with acquired cystic kidney disease (ACKD) and renal tumors.

MATERIALS AND METHODS

Between June 2000 and September 2002, 10 patients with ACKD underwent simultaneous bilateral laparoscopic radical nephrectomy for renal lesions suspicious for carcinoma. The lesions were discovered during pretransplant evaluation in 9 patients and incidentally in 1 renal transplant recipient. A 3- or 4-port transperitoneal approach was used for each side to mobilize the kidney and secure the renal hilum. Both specimens were extracted through a midline supraumbilical incision. Operative time, blood loss, analgesic requirements, hospital stay, and convalescence and recurrence rates were determined.

RESULTS

The mean age of the patients was 41.6 years (range, 29-47 years). Mean operative time was 6.5 hours (range, 4.5-9.7 hours) and mean estimated blood loss was 164 cc (range, 50-300 cc). There was one intraoperative complication-a clotted arteriovenous (AV) graft; and 2 postoperative complications-1 fluid overload and 1 adrenal insufficiency. The average length of hospital stay was 3.1 days (range, 2-4 days) and mean convalescence was 2.8 weeks (range, 1-6 weeks). All cancers were confined to the kidneys and there has been no recurrence during follow-up ranging from 6 to 26 months.

CONCLUSION

Bilateral laparoscopic radical nephrectomy in end-stage renal disease patients is safe and feasible. The advantages of the laparoscopic approach include minimal intraoperative blood loss, shorter hospital stay, minimal postoperative pain, and a rapid return to normal activity. The laparoscopic technique offers an effective, minimally invasive therapeutic alternative to open surgery in high-risk end-stage renal disease patients.

[Two cases of multilocular cystic nephroma, a rare benign tumor of the kidney]

We present two case reports of multilocular cystic nephroma (MCN). MCN is a rare benign tumor of the kidney that is difficult to differentiate from malignant tumor by diagnostic imaging (ultrasound, CT) and cytology on fine-needle aspiration. This is why most cases end up with nephrectomy and diagnosis is based on the histopathological findings. In one of our two cases, a nephrectomy was performed, and in the other the tumor was resected from the kidney. The origin of MCN is uncertain, and only about 200 cases have been reported in the literature.

Long-term results of single-session percutaneous drainage and ethanol sclerotherapy in simple renal cysts

PURPOSE

To demonstrate the efficacy and long-term results of the single-session ethanol sclerotherapy in simple renal cysts.

MATERIALS AND METHODS

Ninety-eight cysts in 97 patients (range: 18-76 years; mean age, 54 years) were included in the study. Indications were determined as flank pain in 74, hydronephrosis in 12, hypertension in 8, patient reassurance due to increasing cyst size in three patients. Mean follow-up period was 24.4 months. Procedures were performed with the guidance of fluoroscopy and ultrasonography at all times using 5-7 Fr pigtail catheters. After the cystogram that was obtained in all cases, 95% ethanol with a volume of 30-40% of the cyst volume was used as a sclerosing agent on an outpatient basis. Maximum volume of the injected ethanol was 200 ml. Follow-up examinations were performed 1, 3, 6 and 12 months after the procedure and once every year thereafter.

RESULTS

Average cyst volume reduction was 93% at the end of the first year. The cysts disappeared completely in 17 (17.5%) patients. After the procedure, in 67 (90%) patients improvement in flank pain was noted. Sixty-one (82%) patients were free of pain and in 6 (8%) of them the pain decreased. Normotension was obtained in 7 (87.5%) of the 8 hypertensive patients and no hydronephrosis was detected in 10 (83.3%) of the 12 patients after the procedure. Second intervention was required in 2 (2%) patients due to recurrence of cysts and related symptoms. One (1%) patient had small retroperitoneal hematoma that resolved spontaneously and in another (1%) patient spontaneous hemorrhage was detected into the cyst 1 year after the procedure. No other complication was detected during the procedure and follow-up.

CONCLUSION

Percutaneous treatment of simple renal cysts with single-session sclerotherapy is a safe, effective and minimally invasive procedure and can be used as an alternative to multiple-session sclerotherapy with comparable results. High volume, up to 200 ml ethanol can be used without adverse effects for large renal cysts.

Retroperitoneoscopic Decortication of Symptomatic Renal Cysts

PURPOSE

To determine the safety and efficacy of retroperitoneoscopic decortication of symptomatic renal cysts.

PATIENTS AND METHODS

A total of 24 patients with symptomatic 6- to 14-cm (mean 10.9-cm) simple renal cysts, right sided in 13 and left sided in 11, underwent retroperitoneoscopic decortication for pain relief at our center between January 1997 and December 2002. The diagnosis was based on an ultrasonogram and contrast-enhanced CT. Symptom severity, assessed using a visual analog pain scale, averaged 7.2/10 (range 6.5-9). The mean duration of symptoms was 4 months. Operative and follow-up data were collected prospectively and analyzed for symptomatic and objective evidence of improvement.

RESULTS

The mean operating time was 95 minutes, and no major complications were observed. The average hospital stay was 2.9 days (range 2-7 days). At a mean follow-up of 2.8 years (range 1.5-5 years), pain relief was reported by 22 patients (change of pain score from 7.2 to 1.4). One patient had worsening of pain at 6 weeks postoperatively. Asymptomatic recurrence of the cyst was seen in two patients on the follow-up ultrasound scans.

CONCLUSIONS

Retroperitoneoscopic renal-cyst decortication is a safe, minimally invasive, and efficacious procedure for the treatment of painful renal cysts, with a durable response.

LAPAROSCOPIC PARTIAL NEPHRECTOMY FOR CYSTIC MASSES

PURPOSE

Although laparoscopic partial nephrectomy (LPN) has emerged as an effective treatment option in select patients with a solid renal tumor, scant data are available on cystic renal tumors. We report our experience with LPN in 50 patients with a cystic renal lesion.

MATERIALS AND METHODS

Of 284 patients undergoing LPN at our institution since August 1999 preoperative computerized tomography identified a suspicious cystic lesion in 50 (17.6%) (group 1). Data were retrospectively compared with those on 50 matched, consecutive patients undergoing LPN for a solid renal mass (group 2). All patients with Bosniak II/IIF cysts were advised to undergo watchful waiting. Surgery was offered if the cyst changed in character or if that was the patient preference.

RESULTS

Median tumor size was 3 cm in group 1 and 2.6 cm in group 2 (p = 0.07). Groups 1 and 2 were comparable in regard to perioperative parameters. In patients with Bosniak II (9), IIF (4), III (12) and IV (21) cysts final histopathology revealed renal cell carcinoma in 22%, 25%, 50% and 90%, respectively. All 100 patients had a negative surgical margin. No patient in group 1 had intraoperative puncture/spillage of the cystic tumor. In group 1 during a mean followup of 14 months (range 1 month to 3 years) 1 patient had retroperitoneal recurrence at 1 year despite negative surgical margins during initial LPN.

CONCLUSIONS

Surgical outcomes of LPN for suspicious cystic masses are similar to those of LPN for solid tumors. However, extreme caution and refined laparoscopic technique must be exercised to avoid cyst rupture and local spillage.

COMPARISON OF PRESENTATION AND OUTCOME FOR PATIENTS 18 TO 40 AND 60 TO 70 YEARS OLD WITH SOLID RENAL MASSES

PURPOSE

We compared histological subtype, pathological features and outcome of patients with solid renal masses who were 18 to 40 years old vs patients who were 60 to 70 years old.

MATERIALS AND METHODS

We conducted a retrospective review of the Mayo Clinic Nephrectomy Registry from 1970 to 2000, and identified 124 patients 18 to 40 years old and 1,067 patients 60 to 70 years old available for analysis.

RESULTS

There was no significant difference in the incidence of benign solid renal masses between patients 18 to 40 years old and those 60 to 70 years old (13.7% vs 10.2%). Among patients with renal cell carcinoma (RCC), younger patients were more likely to have chromophobe RCC (13.1% vs 3.6%) and less likely to have clear cell RCC (70.1% vs 81.5%) than older patients. Among patients with clear cell RCC, younger patients were more likely to have stage pT2b or lower tumors (82.7% vs 69.9%) and a higher incidence of cystic clear cell RCC (10.7% vs 2.2%) than older patients. Younger patients had an improved cancer specific survival compared with older patients but this difference was not statistically significant (risk ratio 0.71, p =0.127).

CONCLUSIONS

We found that patients 18 to 40 years old were more likely to have chromophobe and less likely to have clear cell RCC compared with patients 60 to 70 years old. We did not identify a higher incidence of papillary RCC in younger patients. Patients with clear cell RCC 18 to 40 years old had a higher incidence of low stage and cystic tumors compared with patients 60 to 70 years old, features which have been shown to have a favorable prognosis. These factors likely contributed to improved cancer specific survival for younger patients.

Laparoscopic management of peripelvic renal cysts: University of California, San Francisco, experience and review of literature

OBJECTIVES

To report our experience and review published reports on the laparoscopic management of peripelvic renal cysts. Peripelvic renal cysts represent a unique subset of renal cysts, as they are rare, commonly symptomatic, and more difficult to treat than simple peripheral renal cysts. Minimally invasive methods for the treatment of peripelvic renal cysts, including laparoscopic decortication, have recently become more common.

METHODS

Four patients who presented with symptomatic peripelvic cysts underwent laparoscopic decortication at our institution. All four were men aged 47 to 65 years. One patient had undergone an unsuccessful prior cyst aspiration. All patients underwent preoperative computed tomography and retrograde pyelography. The mean number of peripelvic cysts per patient was 3.0, and the mean cyst size was 7.1 cm.

RESULTS

The mean operative time was 259 minutes (range 240 to 293), and the mean estimated blood loss was 30 mL (range 10 to 50). No evidence of cystic renal cell carcinoma was found on aspiration cytology or cyst wall pathologic examination. The mean hospital stay was 1.3 days. No inadvertent collecting system injuries and no intraoperative or postoperative complications occurred. All 4 patients achieved symptomatic relief and were determined to have radiologic success as determined by the 6-month postoperative computed tomography findings.

CONCLUSIONS

Laparoscopic ablation of peripelvic renal cysts is more difficult than that of simple peripheral renal cysts and demands a heightened awareness of potential complications and, therefore, more advanced surgical skills. In addition to our experience, a thorough review of published reports found this procedure to be safe and effective with appropriate patient selection.

Pitfall in renal cyst surgery: serous cystadenoma of pancreas mimicking renal cyst

Pancreatic lesions, particularly cysts, can simulate various diseases. We report a case of a 43-year-old woman with a large, symptomatic, retroperitoneal cyst misdiagnosed as a "renal cyst." During the retroperitoneoscopic marsupialization, the correct diagnosis of a pancreatic cyst was made, leading to an open pancreas tail resection. Histologic evaluation revealed serous cystadenoma. Especially in large retroperitoneal cysts on the left side, the correct diagnosis of a pancreatic cyst can be difficult.

[Evaluation and prognostic of cystic renal tumors]

OBJECTIVE

To evaluate the clinical and pathological characteristics of cystic renal tumors in our center.

MATERIAL AND METHODS

A retrospective review of 239 nephrectomies is performed comparing the clinical and pathological variables of cystic tumors with those of solid renal tumors. Survival outcomes are analyzed in both groups.

RESULTS

Our experience shows that cystic renal tumors behave like solid renal tumors, with no differences in survival shown. The variables studied show statistically significant differences in histological grade and number of tumors, with cystic tumors having a lower histological grade and being more often multiple in number.

CONCLUSIONS

The behavior of cystic renal tumors is no different than that of solid renal tumors.

Retroperitoneoscopic approach in the treatment of symptomatic renal cysts

INTRODUCTION AND OBJECTIVE

The authors present the results and follow up of patients with simple parenchymal and peripelvic cysts who underwent retroperitoneoscopic cyst decortication.

MATERIAL AND METHODS

The records of 19 patients who underwent 3/4-port retroperitoneoscopic cyst decortication between January 1999 and January 2004 were retrospectively reviewed. All patients admitted to the hospital were symptomatic, the most common presenting syptoms were flank pain (19p) and hematuria (6p). The cyst size ranged from 8 to 15cm (mean size 10cm). 10 cysts were located on the right kidney and 9 cysts on the left kidney. The mean age of patients was 51 years. 16 patients had a simple parenchymal cyst corresponding to Bosniak type I (8 patients underwent cyst aspiration and sclerotherapy with 96 % alcohol in past), 2 patients had peripelvic cyst corresponding to Bosniak type II and 1 patient had a parenchymal cyst Bosniak type II.

RESULTS

Retroperitoneoscopic renal cyst decortication was successfully performed in all patients, no conversion was needed. The mean operative time was 70 min (50-90 min) in patients with parenchymal and peripelvic cysts. The mean operative blood loss was 70 ml (50-130 ml) and the mean lenght of hospital stay was 3 days (2-5 days). The follow up ranged from 6 to 48 months and during that period were all patients asymptomatic, with no signs of recurrence.

CONCLUSIONS

Retroperitoneoscopic cyst decortication is a safe and effective operative procedure in the treatment of symptomatic renal cysts with the minimal complication rate and excellent results (Tab. 2, Fig. 3, Ref. 30).

[Laparoscopic unroofing of peripelvic cyst]

Laparoscopic unroofing of renal cyst has replaced open surgical intervention in recent years. We report our experience with this procedure on 6 patients with hydronephrosis due to peripelvic cyst. Four male and two female patients, ranging from 51 to 67 years, underwent laparoscopic unroofing of peripelvic cyst. All patients had various degrees of hydronephrosis. Two patients had lumbago and hematuria. The cause of this hematuria was probably due to the renal pelvic stone. Surgical approaches i.e., retro- or transperitoneal were selected depending on the location of cyst. The operative time ranged from 80 to 235 minutes (mean 167 minutes). The length of postoperative hospital stay ranged from 3 to 7 days (mean 4.6 days). Intraoperative blood loss ranged from 20 to 26 cc (mean 21 cc). Four weeks after the operation, all patients showed improvement of hydronephrosis. Laparoscopic unroofing of peripelvic cyst is a safe and efficacious procedure, and could be an' attractive alternative for management of peripelvic renal cysts.

Elective open nephron-sparing surgery for renal masses: single-center experience with 129 consecutive patients

OBJECTIVES

To present our experience with elective, open, nephron-sparing surgery for renal masses in a contemporary, consecutive series.

METHODS

In this retrospective study, the files of all patients who underwent elective nephron-sparing surgery between January 1996 and December 2002 at our institution were reviewed. The preoperative workup included renal ultrasonography and abdominal computed tomography. The histologic findings, complications, and oncologic outcome were studied. The surgical technique (ischemia and regional hypothermia) was identical in all patients.

RESULTS

A total of 129 patients (mean age 61 years) were analyzed. The mean +/- standard deviation tumor size on preoperative computed tomography was 4.0 +/- 2.4 cm. Renal cell carcinoma was present in 86 patients (66.7%), a benign cyst in 18 (13.9%), oncocytoma in 10 (7.8%), angiomyolipoma in 7 (5.5%), adenoma in 4 (3.1%), xanthogranulomatous pyelonephritis in 3 (2.3%), and metastasis of a malignant melanoma in 1 patient. Two patients (1.6%) required secondary nephrectomy because of postoperative bleeding. After a median follow-up of 34 months (range 2 to 91), no patient had developed local recurrence, one (0.8%) had developed lymph node metastasis, and two (1.6%) had developed distant metastases. The creatinine clearance decreased from 77 +/- 27 mL/min before surgery to 64 +/- 23 mL/min after a median of 34 months.

CONCLUSIONS

The results of this contemporary, monocenter experience underline the role of open, elective, nephron-sparing surgery for patients with small renal masses, particularly because benign histologic findings were present in almost one third of patients.

[Cystic renal cell carcinoma in childhood: a case report]

Renal cell carcinoma is a common renal malignancy in adults but it is extremely rare in children. An 8-year-old boy visited our hospital with the complaint of right abdominal palpable mass. Computed tomographic (CT) scan revealed a right renal multilocular cystic mass which displaced the normal renal parenchyma. A right radical nephrectomy was done and pathological findings revealed cystic renal cell carcinoma. He received postoperative therapy with the administration of alpha interferon and has been well with no evidence of recurrence nor metastasis during 8 months after surgery. To our knowledge this is the youngest case of cystic renal cell carcinoma reported.

Percutaneous treatment of simple renal cysts with sclerotherapy and extended drainage

PURPOSE

To present the long-term results of sclerotherapy of symptomatic simple renal cysts with alcohol and aethoxysclerol followed by protracted seven-day drainage and to compare the efficacy of the two sclerosing agents used in the therapy.

MATERIALS AND METHODS

Sixty-six symptomatic patients underwent percutaneous treatment with drainage and sclerotherapy of 72 simple renal cysts in a day hospital setting. The cysts were divided into two groups according to size (Group I and Group II with cyst volume smaller or larger than 600 ml respectively) for a better comparison of the results. The cysts were punctured directly under local anaesthesia with a 7 French Trocar catheter using the ''one-shot'' technique and ultrasound guidance; a pig tail catheter was then left in the cyst for the complete evacuation of the cyst fluid. Sclerotherapy was performed by injection of 95% alcohol or 3% aethoxysclerol for 40 minutes, followed by seven-day drainage. On the basis of dimensional criteria, response to treatment was defined as: recovery, partial recurrence or recurrence.

RESULTS

The procedure was successful in 97.2% of the cases with regard to cyst drainage, with clinical recovery in 95.3% of the cases. Group I had 14 recoveries and no complete recurrence after either alcohol or aethoxysclerol, 2 partial recurrences with alcohol and 4 partial recurrences with aethoxysclerol; Group II had 15 recoveries, 14 partial recurrences and one complete recurrence with alcohol, and 5 recoveries, 8 partial recurrences and 2 complete recurrences with aethoxysclerol.

CONCLUSIONS

The one-shot technique under ultrasound guidance prevents the risk of major complications, reduces the likelihood of failure and is inexpensive; furthermore, it significantly reduces procedure time and is better tolerated by patients. On the basis of the clinical and dimensional results obtained, percutaneous sclerotherapy of renal cysts can be recommended as the treatment of choice and as a valid alternative to laparoscopy. As for the comparison between the two sclerosing agents, alcohol has a higher cost and negative side effects, but is more effective for the treatment of larger cysts. Aethoxysclerol is less expensive and has no side effects, but tends to lead to septic complications. On the basis of our experience, we therefore recommend the use of aethoxysclerol for sclerotherapy of smaller cysts followed by a 4-day drainage. For larger cysts, we recommend repeated alcoholization and the removal of the drainage catheter after seven days.

Local recurrence of a unilateral cystic nephroma

Cystic nephroma is an uncommon, benign renal lesion. We report the first case of local recurrence of a unilateral cystic nephroma in an adult. Only three cases of recurrence in bilateral cystic nephroma have been described in the literature before. Other renal lesions may not be differentiated preoperatively from cystic nephroma and thus require surgical exploration. Long-term follow-up is recommended to rule out local recurrence.

Malignant B-cell lymphoma in renal cyst wall

Renal cysts are frequently found in adults older than 50 years of age. Bosniak type III and IV cysts are commonly associated with malignancy, but most Bosniak I and II lesions are benign, and the optimal management has not been clearly defined. Although computed tomography and ultrasound examinations have improved diagnostic accuracy, some masses will remain indeterminate and require more invasive evaluation. We report a patient with a Bosniak type II renal cyst associated with malignant B-cell lymphoma in the cyst wall diagnosed after laparoscopic renal exploration.

Cystic hamartoma of the renal pelvis

Cystic hamartoma of the renal pelvis is a rare benign tumor in the same category as mixed epithelial and stromal tumors. We present a 33-year-old woman with a solid and cystic intrarenal tumor extending into the renal pelvis. She underwent radical nephrectomy and ureterectomy under the diagnosis of renal tumor or renal pelvic tumor. Histopathologically, the tumor was composed of a biphasic proliferation of epithelial and mesenchymal elements. We believe the present case is best classified as a cystic hamartoma of the renal pelvis in the category of mixed epithelial and stromal tumors because of the coexistence of hamartomatous lesions, such as the proliferation of adipose cells and well to poorly differentiated fibromuscular lesions.

Retroperitoneoscopic partial nephrectomy with transient occlusion of renal artery for treatment of small renal tumors

OBJECTIVES

To evaluate the results of retroperitoneoscopic partial nephrectomy with transient occlusion of the renal artery for treatment of patients with small renal tumors.

METHODS

From May 2002 to March 2003, 12 consecutive patients with T1N0M0 renal tumors with a median diameter of 3.0 cm underwent retroperitoneoscopic partial nephrectomy. The renal artery was clamped transiently without occlusion of the renal vein and the tumor was excised with scissors. Intracorporeal renal cooling was achieved by cold saline perfusion of the renal pelvis through a single-J ureteral catheter. Hemostasis was achieved by approximating the renal parenchyma over the perirenal fatty tissue using a retroperitoneoscopic suturing technique.

RESULTS

Of the 12 patients, 11 successfully underwent partial nephrectomy retroperitoneoscopically. The median operative time, renal ischemic time, and amount of blood loss in the successful procedures was 220 minutes (range 132 to 340), 50 minutes (range 16 to 115), and 150 mL (range 50 to 800), respectively. The renal calix was opened and repaired in 10 patients. The surgical margin was negative in all patients. The postoperative course was uneventful in all patients, and the return to work was achieved in a median of 18 days (range 9 to 39). The renal function of the affected kidney was well preserved postoperatively, when examined by renal scintigraphy. Neither local recurrence nor distant metastasis was found during the median follow-up period of 10 months (range 1 to 18).

CONCLUSIONS

Retroperitoneoscopic partial nephrectomy with transient occlusion of the renal artery is a useful and less-invasive method for resection of small renal tumors. Additional technologic developments to reduce ischemic times and to cool the kidneys laparoscopically are required.

Utility of frozen section analysis of resection margins during partial nephrectomy

OBJECTIVES

To evaluate the utility of routine intraoperative frozen-section histologic analysis during partial nephrectomy to ensure negative surgical margins. Partial nephrectomy has gained acceptance for surgical treatment of small renal cancers. Many surgeons send specimens for intraoperative frozen section histologic analysis to ensure negative margins.

METHODS

We reviewed the records of 78 patients who underwent partial nephrectomy for presumed malignancy. Patient demographics, intraoperative findings, and pathologic and clinical outcomes were analyzed.

RESULTS

Seventy-nine partial nephrectomies were performed in 78 patients. Frozen sections were obtained intraoperatively in 76 cases. In 1 case (1.3%), a single margin was interpreted as positive for carcinoma, prompting deeper resection. The final histopathologic finding was interpreted as angiomyolipoma rather than carcinoma. The final pathologic examination revealed renal cell carcinoma in 52 (66%) of 79 cases. The mean oncologic follow-up was 16.2 months. One local recurrence was noted (1.9%). It arose in the resection bed 19 months after removal of a 4.5-cm tumor (pathologic Stage T3a). Both intraoperative frozen section margins and final pathologic margins were negative in this case. One patient developed pulmonary metastases and represented the only metastatic recurrence, as well as the only cancer-related death in our cohort (1.9%).

CONCLUSIONS

Our data suggest that when partial nephrectomy is performed with attention to excising a perimeter of grossly normal-appearing parenchyma, sending specimens for intraoperative frozen section analyses may provide an unnecessary expense without providing meaningful, reliable information. Additional studies, including larger cohorts and extended follow-up, are needed to support these results.

Small renal oncocytoma with central cystic degeneration

A case of a small renal oncocytoma with central cystic degeneration, 15 mm in diameter, is reported. Contrast-enhanced computed tomography showed the tumor contained a central hypoattenuating region and had an irregular, heterogeneously enhanced wall. Magnetic resonance images showed a well-circumscribed lesion and the T(1)-weighted image indicated medium signal intensity, whereas the T(2)-weighted image indicated slight hypointensity. Both T(1)- and T(2)-weighted images showed central hyperintensity. Our preoperative diagnosis was renal cell carcinoma originating in a renal cyst wall or cystic renal cell carcinoma. Nephrectomy was performed because frozen-section examination did not completely rule out malignancy. The final pathological diagnosis of the entire surgical specimen was renal oncocytoma with cystic degeneration. To our knowledge, this is the 14th case of renal oncocytoma with central cystic degeneration reported in the published works. We discuss herein the variant forms of oncocytoma and difficulties with their preoperative diagnosis, especially when the tumor is small.

[Diagnosis and treatment of multilocular cystic renal cell carcinoma: a study of 22 cases]

OBJECTIVE

To summarize the diagnosis and treatment of multilocular cystic renal cell carcinoma (MCRCC), a special subtype of renal cell carcinoma.

METHODS

The clinical data of 22 cases of MCRCC diagnosed and treated from January 1998 to December 2002 in the First Hospital of Peking University were analyzed retrospectively.

RESULTS

482 patients with renal cell carcinomas were hospitalized during that period with a male-to-female ratio of 2.09:1. Out of the 482 cases 22 cases (4.56%) were classified as MCRCC with a male-to-female ratio of 2.67:1, not significantly different from that of the general group of renal cell carcinoma patients (P > 0.05). The mean age of the patients of MCRCC was 46.6 years, significantly lower than that of the patients with other types of renal cell carcinomas (57.83 years, P< 0.01). Eighteen cases were diagnosed correctly as renal carcinomas before operation. Six patients (27%) were at the stage pT(1)N(0)M(0), 15 (68%) at the stage pT(2)N(0)M(0), and 1 (5%) at the stage pT(3)bN(0)M(0). The classification according to the tumor nuclear grading system showed 5 carcinomas (23%) of tumor nuclear grade 1, 17(77%) are of tumor nuclear grade 2. Eighteen patients underwent radical renal nephrectomy and 4 underwent partial nephrectomy.

CONCLUSION

The preoperative diagnosis of MCRCC, difficult to be differentiated from other cystic renal diseases, mainly depends on imaging studies. Intraoperative frozen-section or nephron sparing surgery will benefit the patients if the preoperative diagnosis is unclear, especially for the patients of category 3 or 4 of Bosniak's system.

[Retroperitoneoscopic operations in cystic lesions of the kidneys]

In 1997-2002 retroperitoneoscopic dissection of renal cyst walls (RDRC) was made in 21 patients. Computed tomography, excretory urography, retrograde ureteropyelography were conducted in 14, 3 and 2 patients, respectively. Ultrasonic investigation was made in all the patients before and after operation. Dissection of the cystic walls was successful in 20 of 21 patients, material for cytological and histological examinations was also obtained. Advantages of endoscopic operations are now obvious, so RDRS is perspective in cystic lesions of the kidneys and its usage will increase.

Long-Term Outcome of Laparoscopic Decortication of Peripheral and Peripelvic Renal and Adrenal Cysts

PURPOSE

We determined the perioperative course of laparoscopic decortication of renal/adrenal cysts, and the association among cyst location, radiographic assessment and long-term symptom relief.

MATERIALS AND METHODS

Laparoscopic cyst decortication was performed 18 times in 17 patients for pain relief (1 patient had bilateral cysts) at our institution between August 1996 and June 1999. Of these patients 13 had single and 5 had multiple cysts, and 9 each had peripelvic and peripheral (includes 2 adrenal) cysts. Questionnaires were prospectively distributed to these patients preoperatively, 2 and 6 weeks postoperatively, and annually thereafter. Preoperative and postoperative radiographs were reviewed.

RESULTS

Perioperative morbidity measures were similar to those previously published with minimal complications and a rapid recovery. Cyst location had no significant perioperative impact. Symptom relief occurred in 78% of cases overall. Median final symptomatic followup was 52 months. Radiographic success (complete absence of cyst) was 89% for the peripheral cyst group and 55% for the peripelvic cyst group (p = 0.29). Median radiographic followup was 23 months. Symptomatic failure occurred in 40% of the 5 radiographic failures and 15% of the 13 radiographic successes (p = 0.53).

CONCLUSIONS

Laparoscopic decortication is a safe, minimally invasive and effective treatment for symptomatic renal cysts with durable response. Although peripelvic cyst location can make certain cases more difficult or even technically not feasible, perioperative measures and long-term outcome are generally equivalent. Symptomatic failure after complete cyst resection, as measured radiographically, is likely due to a misdiagnosis of the cause of symptoms.

Laparoscopic Ablation of Symptomatic Peripelvic Renal Cysts

PURPOSE

We report our experience with laparoscopic ablation of symptomatic peripelvic renal cysts.

PATIENTS AND METHODS

Two men and two women (mean age 58) with a peripelvic renal cyst associated with ipsilateral flank pain and obstruction were treated by transperitoneal laparoscopic ablation. One patient had an episode of pyelonephritis before detection of the cyst. Cyst size ranged from 4.5 to 6.5 cm (mean 5.5 cm). Dissection of the cyst was intricate because of the close proximity to the renal hilum and the compressed collecting system. Patients were followed with radiologic imaging at 6 and 12 months and once a year thereafter.

RESULTS

In all cases, the laparoscopic procedure was successful. The operative time ranged from 120 to 190 minutes (mean 155 minutes), and the mean blood loss was <150 mL. The mean postoperative hospital stay was 2.7 days (range 2-5 days), and the time of convalescence was 14 days. Complications consisted of a subcutaneous hematoma. At a mean follow-up of 23 months, symptoms and collecting system obstruction had resolved in all patients.

CONCLUSION

Although laparoscopic ablation of peripelvic renal cysts is technically challenging, it is a safe and efficacious procedure and offers a favorable minimally invasive alternative for the treatment of symptomatic cysts.

Laparoscopic management of symptomatic simple renal cysts

OBJECTIVE

To evaluate the efficacy of retroperitoneoscopy for the treatment of symptomatic renal cyst disease.

PATIENTS AND METHODS

We evaluated the efficacy and morbidity of aspiration versus open and laparoscopic surgical techniques in a paired institution over a 20-year period. Prospectively recorded parameters for the 11 cases dealt with by primary retroperitoneoscopic techniques were compared with historical controls dealt with by open surgery.

RESULTS

Small volume cysts were satisfactorily dealt with by aspiration alone. All patients undergoing laparoscopic cyst decortication for the larger volume cysts had a satisfactory outcome with improvement in their symptoms and objective cure on follow up imaging studies.

CONCLUSION

Laparoscopic management for all cysts is a safe, effective and minimally invasive alternative to open surgery for symptomatic renal cysts. Simple drainage under radiological guidance is also highly effective and should probably be first line treatment for cysts up to 6 cms in diameter whereas primary laparoscopic treatment should be suggested for larger cysts.

Long-Term Results of Transperitoneal Laparoscopic Fenestration in the Treatment of Simple Renal Cysts

The aim of this paper was to assess long-term results of transperitoneal laparoscopic fenestration in the treatment of symptomatic simple renal cysts. Fifteen consecutive patients (7 men, 8 women), with a mean age of 51 years (range, 36-79 years), underwent transperitoneal fenestration of simple renal cysts (SRC) at our institution from 1994 to 2001. Data were collected by reviewing patients' clinical files, conducting telephone interviews regarding symptoms, and followup renal ultrasonography (US). There were 15 symptomatic cysts (10 parenchymal, 5 peripelvic) ranging in diameter from 3.5 to 20 cm (mean, 8 cm). All patients had lumbar pain and in four (26.6%) the collecting system was compressed by the cysts. Fenestration was carried out laparoscopically in all patients. There was no mortality and no postoperative complications were recorded. No malignancies were detected at final histopathology. Mean length of stay was 2.5 days. All patients were available for long-term followup. At a mean of 60 months (range, 22-93 months) from surgery, three patients (20%) complained of slight discomfort in the lumbar area not requiring any analgesic. No recurrence of the cysts was seen on US. Two asymptomatic patients (13.3%) developed additional cysts originating from sites different than the one operated on. Laparoscopic fenestration of SRC is safe and effective in the long term to relieve patients from symptoms.

Retroperitoneoscopic Deroofing of a Giant Renal Cyst in a Solitary Functioning Hydronephrotic Kidney With a 3-port Technique

To explore the safety and feasibility of performing retroperitoneoscopic renal cystectomy in a case of massive giant renal cyst in a solitary hydronephrotic renal unit. We have described the retroperitoneal three-trocar technique. The role of laparoscopic renal cyst ablation in giant symptomatic renal cysts and non-polycystic kidney disease has been discussed. The patient was successfully managed by retroperitoneoscopic deroofing using a three-port technique. The operating room time was 90 minutes and her hospital stay lasted 54 hours. The fluid cytology and cyst histology were negative for tumor. Complete resolution of the cyst was noted on a follow-up ultrasound done after 2 months. Currently at 9-month follow up, the patient is ultrasonographically free of any cyst recurrence or hydronephrosis. The retroperitoneal approach is feasible for marsupializing giant symptomatic renal cysts and appears to be safe for solitary symptomatic renal units too. It shortens the overall operating time and avoids the complications and demerits of transperitoneal access.

Nephron-sparing surgery for multilocular cyst of the kidney in a child

Multilocular cyst of the kidney is an uncommon benign renal neoplasm. Because of its benign nature, this lesion is best managed by nephron-sparing surgery. This report describes a child who underwent a partial nephrectomy for a multilocular cyst of the kidney. After reviewing other cases, we discuss the clinical characteristics of multilocular cyst of the kidney and emphasize the cystic partially differentiated nephroblastoma as a differential diagnosis.

Laparoscopic Ablation of Giant Renal Cyst

We report a case of a symptomatic giant (18 x 10 x 8-cm) renal cyst in a 40-year-old woman that was marsupialized laparoscopically and excised. The surgical technique, based on progressive decompression of the cyst, is fully described. Excellent results were achieved. The recent application of laparoscopic ablation of different types of renal cysts is reviewed. This minimally invasive technique, when properly mastered, is highly effective and offers results similar to those of open surgery. It is associated with definitive postoperative advantages and is the treatment of choice for very large renal cysts, especially those located anteriorly, when sclerotherapy is ineffective or is contraindicated.

Cystic renal cell carcinoma, suspected because of lack of regression of renal cysts after renal transplantation in a dialysis patient with acquired renal cystic disease

A 34-year-old man who had been on dialysis for about 6 years, and had acquired renal cystic disease, received a renal transplantation. However, in spite of the success of the transplantation, one area without cyst regression was observed in the original kidney. Therefore, carcinoma was suspected and nephrectomy was performed. Histology revealed cystic renal cell carcinoma (RCC). No case of cystic RCC occurring in a dialysis patient has previously been reported. Cystic RCC should be suspected in a cystic mass in the original kidney which does not regress after successful renal transplantation.

A comparison of aspiration and sclerotherapy with laparoscopic de-roofing in the management of symptomatic simple renal cysts

OBJECTIVES

To present the results of a minimally invasive treatment of symptomatic simple renal cysts, and to propose an algorithm for their management.

PATIENTS AND METHODS

Seventeen patients presenting with suspected symptomatic simple renal cysts were referred for trial aspiration; 16 presented with loin pain and one with a flank mass. If the cyst and symptoms recurred after a temporary response, they were managed by re-aspiration with sclerotherapy using 95% ethanol, or by laparoscopic de-roofing of the cyst.

RESULTS

Of the 17 patients referred, one failed to respond to aspiration and was excluded from further analysis. Three patients had sustained pain relief from simple aspiration alone, 13 required further treatment for symptom relapse, of whom six had aspiration and sclerotherapy, and seven had laparoscopic de-roofing. After a mean follow-up of 17 months, pain had recurred in all five patients originally presenting with pain and managed by sclerotherapy, and the patient who presented with a painless mass from a large cyst also developed pain after sclerotherapy. In contrast, the subsequent seven patients managed by laparoscopic treatment are pain-free at a mean follow-up of 17.7 months.

CONCLUSION

Evaluation including a diagnostic aspiration is essential to diagnose a symptomatic cyst. When treatment is indicated, laparoscopic de-roofing appears to be more effective than sclerotherapy.

Follow-up CT of moderately complex cystic lesions of the kidney (Bosniak category IIF)

OBJECTIVE

The purpose of this study is to show the use of follow-up CT studies in the management of moderately complex cystic lesions of the kidney (Bosniak category IIF).

MATERIALS AND METHODS

The CT scans of 42 moderately complex cystic renal masses (Bosniak category IIF) with follow-up examinations for 2 years or greater or with pathology correlation (n = 3) were retrospectively analyzed by the authors in consensus. The complexity of each lesion was assessed on the basis of the number and appearance of the septa, wall thickness, interface with the kidney parenchyma, presence and amount of calcification, and contrast enhancement characteristics. Lesion size was measured in two dimensions. Follow-up examinations were evaluated for any interval change.

RESULTS

The average size of the lesions was 3.9 x 3.6 cm, and the average follow-up time was 5.8 years (range, 2 years-18 years 4 months; median, 5.0 years). Eighteen lesions had fewer than five septa, 16 lesions had between five and nine septa, and eight lesions had more than nine septa. In 39 lesions, the wall or septa or both were slightly thickened, and in a single lesion, the wall and septa were hairline thin. The two remaining lesions were of uniformly high attenuation and completely intrarenal. Forty-one lesions had a sharp interface with the kidney, whereas one had an indistinct interface. Twenty lesions contained calcium. Enhancement was not shown in any lesions except for minimal enhancement of smooth walls or septa of some lesions. Follow-up examinations showed that three lesions had developed more calcification, one lesion had increased in overall size but appeared less complex, and three lesions had decreased in size. In addition, two lesions had become more complex and developed thicker septa, and these lesions proved to be cystic neoplasms.

CONCLUSION

Follow-up CT studies are an effective way of managing patients with moderately complex cystic lesions of the kidney (Bosniak category IIF) because the absence of change supports benignity and progression indicates neoplasm.

Eine seltene Komplikation der aortoiliakalen Chirurgie: Blutung als Folge einer traumatischen Nierenzystenruptur

The authors describe a clinical case of a retroperitoneal hemorrhage due to rupture of a voluminous renal cyst during a conventional open aortic surgery. Intraoperative trauma is to be considered the cause of bleeding. In most cases the clinical evolution of the patient is benign and conservative treatment is sufficient. Considering the incidence of renal cysts in patients ungergoing conventional aortic surgery, we want to emphasize this possible complication, that has only rarely been dealt with in the literature. We recommend evaluation of such patients in view of preoperative drainage of large cyst including injection of sclerosing agents.