LAPAROSCOPIC BILATERAL HAND ASSISTED NEPHRECTOMY FOR AUTOSOMAL DOMINANT POLYCYSTIC KIDNEY DISEASE: INITIAL EXPERIENCE

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

BACKGROUNDS

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

METHODS

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

RESULTS

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

CONCLUSION

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

Patient-reported outcome measures for pain in autosomal dominant polycystic kidney disease: A systematic review

Pain is a common symptom in people with autosomal dominant polycystic kidney disease (ADPKD), but it is assessed and reported inconsistently in research, and the validity of the measures remain uncertain. The aim of this study was to identify the characteristics, content, and psychometric properties of measures for pain used in ADPKD. We conducted a systematic review including all trials and observational studies that reported pain in people with ADPKD. Items from all measures were categorized into content and measurement dimensions of pain. We assessed the general characteristics and psychometric properties of all measures. 118 studies, we identified 26 measures: 12 (46%) measures were developed for a non-ADPKD population, 1 (4%) for chronic kidney disease, 2 (8%) for polycystic liver disease and 11 (42%) specifically for ADPKD. Ten anatomical sites were included, with the lower back the most common (10 measures [39%]), four measurement dimensions (intensity (23 [88%]), frequency (3 [12%]), temporality (2 [8%]), and sensory (21 [81%]), two pain types, nociceptive including visceral (15 [58%]) and somatic (5 [20%]), and neuropathic (2 [8%]), and twelve impact dimensions, where the most frequent was work (5 [31%]). The validation data for the measures were variable and only the ADPKD Impact Scale reported all psychometric domains. The measures for pain in ADPKD varied in terms of content and length, and most had not been validated in ADPKD. A standardized psychometrically robust measure that captures patient-important dimensions of pain is needed to evaluate and manage this debilitating complication of ADPKD.

Simultaneous bilateral laparoscopic nephrectomy with kidney transplantation in patients with ESRD due to ADPKD: A single-center experience

Patients with autosomal dominant polycystic disease (ADPKD) may require bilateral nephrectomy (BN) in addition to kidney transplantation (KT) for symptom control. This study aims to compare simultaneous BNKT to contemporaneous controls by reviewing our cohort of ADPKD patients who underwent KT from a living donor from January 2014 to October 2019. Symptomatic patients who underwent laparoscopic BNKT were compared to KT alone. Clinical differences related to undertaking bilateral nephrectomies showed increased total kidney volumes (P < .001). We assessed operative parameters, complications, and clinical outcomes. The complications were classified according to the Clavien-Dindo system. In 148 transplant recipients, 51 underwent BNKT, and 97 KT alone. There was no difference in baseline demographics. BNKT recipients had longer cold ischemia time, required more ICU care, increased blood transfusions and longer hospital stays. The kidney function was similar in the first year in both groups, with no difference in delayed graft function, readmissions or severe grade III and IV complications within 3 months after surgery. Laparoscopic BNKT is safe and feasible at the time of living donor KT. Although higher acuity care is needed with a longer initial hospital stay, there are comparable posttransplant patient and allograft outcomes.

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

OBJECTIVE

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

MATERIALS AND METHODS

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

RESULTS

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

CONCLUSION

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

Efficacy and utility of robotic single-access bilateral nephrectomy (r-SABN) in end-stage renal disease patients

PURPOSE

Bilateral native nephrectomies are needed in ESRD patients with select indications in a pre-transplant setting. Yet, the perioperative morbidity is significant in this population. Herein we evaluate the efficacy and utility of r-SABN.

METHOD

A total of 12 patients were consented at a single center. Of 12 patients, 3 patients did not meet study criteria and were excluded. Preoperative, perioperative, and postoperative data were prospectively collected from 9 patients from electronic health records and administered postoperative surveys. Patients were assessed at 30-180 days postoperatively for follow-up.

RESULTS

Mean operative time was 204.3 ± 59.7 min (142.0-314.0) and estimated blood loss during operation was 94.4 ± 87.3 ml (25.0-300.0). The mean length of hospital stay was 2 ± 0.7 days (1-3) for all patients. Total post-operative opioid usage was normalized to morphine dose equivalents (MDE) and calculated to be 56.1 ± 30.4 mg (30.8-101.8). Patients experienced a fourfold and tenfold respective increase in weekly structural and incidental physical activity from 30 to 180 days postoperatively. There were no procedure related intraoperative or postoperative complications reported in the cohort.

CONCLUSION

Overall, r-SABN afforded the patients low morbidity. Longitudinal studies are in progress to further assess the efficacy and outcome of this procedure. In a single-center study, we demonstrate r-SABN is viable and provides a novel tool for treatment of ESRD patients requiring this procedure.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Optimized Retroperitoneoscopic Excision of Large (>25 cm) Adult Polycystic Kidneys Using 3-Dimensional Image Reconstruction and Preresection Ultrasound-Guided Aspiration: Technique and Early Outcomes

BACKGROUND

Laparoscopic excision of large polycystic kidneys remains a challenging procedure. Most of the literature describes transperitoneal approaches. Alterations in anatomy due to size of kidneys can make vascular and hilar control difficult. Retroperitoneal access with direct control of pedicle avoids risks without dissection for structures anterior to the kidneys. The technique of retroperitoneoscopic excision of massively enlarged kidneys is described with early outcomes.

METHODS

Patient DICOM images of kidneys were segmented and reconstructed for 3-dimensional visualization before surgery. Total excision of large polycystic kidneys was performed in 10 patients (11 procedures). After creation of retroperitoneal space, renal pedicle dissection was started with the incision of thinned out Gerota's fascia. Occasionally aspiration of large cysts using ultrasound assistance created space for precise dissection. Following control of vascular pedicle under laparoscopic vision, further aspiration of cysts was accomplished with the help of 3-dimensional reconstructed kidney. Postaspiration, remaining renal specimen was extracted through a small incision using an endobag or as an intact specimen.

RESULTS

The operative time was between 180 and 240 minutes (median 200 minutes). Intraoperative blood loss was 100 to 300 mL (median 175 mL). Median time to control pedicle was 12 minutes (range 10-25 minutes). The postoperative periods were uneventful, except for blockage of arteriovenous fistula in 1 patient. Mean hospital stay was 7 days (range 6-14 days).

CONCLUSIONS

The retroperitoneasocopic approach to large polycystic kidneys under the guidance of 3-dimensional image reconstruction, occasionally with the assistance of ultrasound aspiration is technically feasible, safe, with good perioperative outcomes. It facilitates early control of vascular pedicle with minimal risk of intraoperative bleeding.

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

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

Pain in chronic kidney disease: a scoping review

There is increasing international attention in efforts to integrate palliative care principles, including pain and symptom management, into the care of patients with advanced chronic kidney disease (CKD). The purpose of this scoping review was to determine the extent, range, and nature of research activity around pain in CKD with the goal of (i) identifying gaps in current research knowledge; (ii) guiding future research; and (iii) creating a rich database of literature to serve as a foundation of more detailed reviews in areas where the data are sufficient. This review will specifically address the epidemiology of pain in CKD, analgesic use, pharmacokinetic data of analgesics, and the management of pain in CKD. It will also capture the aspects that pertain to specific pain syndromes in CKD such as peripheral neuropathy, carpal tunnel syndrome, joint pain, and autosomal dominant polycystic kidney disease.

Native nephrectomy in transplant patients with autosomal dominant polycystic kidney disease

INTRODUCTION

This study examined the clinical indications and timing for native nephrectomy (NN), together with the associated pathological findings in transplant patients with autosomal dominant polycystic kidney disease (ADPKD) at our institute over a period of 20 years.

METHODS

A retrospective review was performed of ADPKD patients who had undergone both kidney transplantation and NN. Patients were identified from the kidney transplant database between 1988 and 2008 at Guy's and St Thomas' Hospital and the notes reviewed. All NN specimens were re-reviewed and reported according to current guidelines.

RESULTS

There were 157 kidney transplants performed for ADPKD (114 cadaveric and 43 living donor). Of these, 31 required NN (28 bilateral). The timing of NN was pre-transplant in 10 cases, at the time of the transplant in 1 case and post-transplant in 20 cases. The indications for NN were urinary tract infection (n=14, 45%), pain (n=12, 39%), tumour suspicion (n=3, 10%), haematuria (n=1, 3%) and space (n=1, 3%). Mortality in this NN series was 3%, with a 65% surgical morbidity rate. The length of hospital stay post-NN was significantly longer with open compared with laparoscopic techniques (p=0.003). There were two renal cell carcinomas (RCCs) in this series. Both patients presented with macroscopic haematuria (bilateral pT1a papillary RCCs in one case and a pT3b clear cell RCC in the other case). The incidence of RCC in this series of ADPKD transplant patients was 1.3%.

CONCLUSIONS

We have demonstrated that the majority of ADPKD patients do not require NN, with only 20% of our series undergoing this procedure. The timing of NN is variable and dictated by indication. NN was only required to make space for transplantation in one case (combined kidney and pancreas transplant). The main indications for NN were recurrent infection and pain, where NN can provide a successful outcome. Laparoscopic NN can be performed safely in patients with ADPKD. Haematuria in such patients should not be assumed to be of benign origin and requires exclusion of urinary tract malignancy as the incidence of RCC in this population is at least as common as in the general population.

Outcome of hand assisted laparoscopic bilateral native nephrectomy in transplant recipients

PURPOSE

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

MATERIALS AND METHODS

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

RESULTS

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

CONCLUSIONS

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

Bilateral hand-assisted retroperitoneoscopic nephroureterectomy (HARN) in the spread-eagle position for dialysis patients-low midline HARN in a completely supine position

OBJECTIVES

To evaluate the feasibility of hand-assisted bilateral retroperitoneoscopic nephroureterectomy (HARN) in a completely supine position (spread-eagle position [SEP]) for dialysis patients with bilateral upper urinary tract tumors.

METHODS

From October 2006 to May 2009, bilateral HARN with open bladder cuff excisions were performed in 13 dialysis patients with upper urinary tract tumors. The patient was placed supine with both legs extended and abducted at 45-60 degrees and both arms stretched out to the sides in a SEP. The operation was completed via a 7- to 8-cm lower midline incision and 4 laparoscopic ports (2 on each side).

RESULTS

All procedures were successful. The mean operation time of bilateral HARN and open bladder cuff resection was 215 minutes, and the mean estimated blood loss was 216 mL. The time to oral intake was 2.5 days and to ambulation was 4.3 days. All patients recovered uneventfully to normal daily activity. No specific complication was related to the position.

CONCLUSIONS

Bilateral HARN in a completely supine, SEP position is feasible and safe. SEP has several advantages, including ease in patient positioning, and the feasibility to perform simultaneous bilateral nephroureterectomy without repositioning of the patient. It also avoids potential risks associated with the lateral decubitus position. Bowel interference of the visual field and mechanical bowel injury are not concerns in this approach. Our experience shows that a completely supine position is not only possible but also advantageous to bilateral HARN.

Evaluation and management of pain in autosomal dominant polycystic kidney disease

Transient episodes of pain are common in autosomal dominant polycystic kidney disease (ADPKD). A small fraction of patients have disabling chronic pain. In this review, we discuss the etiologies of pain in ADPKD; review how ADPKD patients should be assessed; and discuss medical, surgical, and other management options.

Retroperitoneoscopic nephrectomy for autosomal dominant polycystic kidney disease: initial experience

INTRODUCTION

Nephrectomy for autosomal dominant polycystic kidney disease (ADPKD) has been reported to have significant morbidity and mortality. Because of the large kidney size, laparoscopic nephrectomy is technically demanding and there have been only few reports on this subject. We describe our retroperitoneoscopic technique and review the literature.

METHODS

Retroperitoneoscopic nephrectomy was performed in 2 patients. A four-port retroperitoneal access was used, after hilar control the kidney was freed and extracted.

RESULTS

The mean operative time was 155 min, the mean intraoperative blood loss was 125 ml. There were no intraoperative complications. A postoperative retroperitoneal hematoma in 1 of the patients was managed conservatively with transfusion.

CONCLUSION

Retroperitoneoscopic nephrectomy for ADPKD is feasible. The main advantages of this technique compared to transperitoneal laparoscopy are the quick and easy access to the hilar vessels even in large polycystic kidneys and the strict extraperitoneal route.

Limitations of laparoscopy for bilateral nephrectomy for autosomal dominant polycystic kidney disease

PURPOSE

We retrospectively studied outcomes following bilateral hand assisted laparoscopic nephrectomy.

MATERIALS AND METHODS

We retrospectively reviewed the charts of 18 patients with symptomatic autosomal dominant polycystic kidney disease who underwent bilateral hand assisted laparoscopic nephrectomy. Preoperative radiographic imaging was reviewed retrospectively to determine kidney size based on an ellipsoid shape. A visual analog pain scale with scores of 0 to 10 to assess pain related to autosomal dominant polycystic kidney disease was measured preoperatively and postoperatively.

RESULTS

Average patient age was 48.2 years (range 30 to 64). Of the patients 14 successfully underwent bilateral hand assisted laparoscopic nephrectomy, while 4 required open conversion. A total of 16 patients underwent nephrectomy for pain and 2 underwent surgery for frequent recurrent symptomatic urinary tract infections. All patients except 1 underwent renal transplantation before bilateral nephrectomy. There was a significant difference in the volume of the right and left kidneys between the hand assisted laparoscopic and open groups (mean +/- SD 1,043 +/- 672 and 1,058 +/- 603.8 vs 4,052 +/- 548 and 3,592 +/- 1,752 cm(3), p <0.001 and 0.06 respectively). There were 5 complications, including wound infection and protracted ileus in 2 patients each, and incisional hernia in 1. In addition, the difference in mean preoperative and postoperative visual analog pain scores was statistically significant (6.9, range 3 to 10 and 0.5, range 0 to 2, p <0.05).

CONCLUSIONS

Bilateral laparoscopic hand assisted nephrectomy is a safe and reliable option in patients requiring removal of the 2 kidneys in a single setting. Rather than performing staged nephrectomies, hand assisted laparoscopic nephrectomy allows the single administration of general anesthesia and provides effective relief of bothersome symptoms in patients with symptomatic autosomal dominant polycystic kidney disease. This procedure is safe in patients with renal transplants. Patients with massive polycystic kidneys with a kidney volume of greater than 3,500 cc are at increased risk for open conversion and they may have improved outcomes if open nephrectomy is attempted from the outset.

Organ intact retrieval via umbilical incision after simultaneous bilateral laparoscopic radical nephrectomy for renal masses

PURPOSE

We report on two cases of laparoscopic bilateral nephrectomy for renal-cell carcinoma (RCC) in patients with end-stage renal disease.

PATIENTS AND METHODS

Bilateral renal masses were detected in two patients with acquired renal cystic disease. They underwent bilateral laparoscopic nephrectomy. The specimens were removed intact via an umbilical incision.

RESULTS

The operative times were 8 hours and 6 hours and the estimated blood loss was 154 mL and 120 mL. Both patients resumed oral intake on postoperative day 1 and were discharged on postoperative day 6. No intraoperative and postoperative complications occurred. The pathology report revealed bilateral RCC. The original length of the umbilical incision was 4 cm which shrank to 3 cm by 2 months after the operation.

CONCLUSIONS

Bilateral laparoscopic radical nephrectomy including intact organ retrieval for bilateral renal masses via a small umbilical incision is feasible.

Bilateral nephrectomy of huge polycystic kidneys associated with a rectus abdominis diastasis and umbilical hernia

BACKGROUND

Patients with end-stage renal failure due to huge autosomal dominant polycystic kidney disease usually have an umbilical hernia and rectus abdominis diastasis, which are very troublesome. Pretransplant bilateral nephrectomy techniques does not manage the umbilical hernia and rectus abdominis diastasis. We report our experience in performing bilateral nephrectomy and repairing the rectus abdominis diastasis and umbilical hernia through the one, small incision.

METHODS

Four patients aged 37 to 43 years with huge polycystic kidneys, an umbilical hernia, and a rectus abdominis diastasis underwent bilateral pretransplant nephrectomy through a midline supraumbilical incision including the umbilical hernia defect. The kidneys were removed through this incision. The incision was closed with the transposition of rectus abdominis muscle, pants-over-vest-style, to correct the diastasis and the umbilical hernia.

RESULTS

The average operative time was 160 minutes (range, 130-180); the average larger kidney size was 33 cm (range, 32-34 cm); no major complications occurred; one patient who had preoperative low hemoglobin required blood transfusion. Patients were discharged from the hospital on postoperative day 7 with an esthetically pleasing belly, no rectus abdominis diastasis, and no umbilical hernia. One to two months after bilateral nephrectomy, the patients received a live donor kidney with an uneventful outcome.

CONCLUSION

A midline supraumbilical incision is an excellent approach for bilateral nephrectomy of huge polycystic kidneys. In addition, an umbilical hernia and rectus abdominis diastasis may be successfully repaired through same incision with good cosmetic results.

A novel approach to bilateral hand-assisted laparoscopic nephrectomy for autosomal dominant polycystic kidney disease

PURPOSE

Laparoscopic nephrectomy in patients with autosomal dominant polycystic kidney disease (ADPKD) is technically challenging. We describe our technique and present our experience with a transperitoneal hand-assisted laparoscopic (HAL) technique using a standard vacuum curettage system to reduce the size of the kidneys thereby facilitating nephrectomy.

MATERIALS AND METHODS

A retrospective review was completed of 10 consecutive patients undergoing bilateral HAL nephrectomy between March 2002 and October 2004 using the following technique. A hand port is positioned through a 6-7 cm periumbilical incision and port sites are placed at the midclavicular line (12 mm) and anterior axillary line (5 mm) on the side of the initial nephrectomy. After the renal vessels are divided and the kidney is completely mobilized a 12 mm curette is inserted through the medial port site. The Berkeley VC-10 Vacuum Curettage System (ACMI, Southborough, MA) is used to morcellate and aspirate the kidney providing a significant decrease in the overall size and allowing easy extraction through the midline incision. The procedure is repeated for the contralateral side.

RESULTS

All 10 patients underwent successful bilateral HAL nephrectomy with a mean operative time of 194 minutes. The average length of stay was 4.7 days. Patients with renal allografts had stable function at the time of discharge. The average size of the kidneys removed was 717 g and average length was 19 cm. All patients did well postoperatively with complete resolution of their presenting symptoms.

CONCLUSION

In patients with symptomatic ADPKD, bilateral HAL nephrectomy using the vacuum curettage system to minimize the size of the kidneys is fast, safe and effective.

Simultaneous transabdominal bilateral nephrectomy in potential kidney transplant recipients

BACKGROUND

Bilateral nephrectomy of potential kidney graft recipients is indicated for patients with recurrent infections in the polycystic kidneys or chronic pyelonephritis resulting from vesicoureteric reflux. The aim of this study was to analyze the frequency of complications after simultaneous bilateral transperitoneal nephrectomy.

PATIENTS AND METHODS

Twenty hemodialysis patients (age 28 to 55 years) were referred for simultaneous bilateral nephrectomy between 1996 and 2004. Among the 18 patients with autosomal-dominant polycystic kidney disease, 11 experienced recurrent cysts or urinary tract infections and two, episodes of disabling flank pain. Five patients with extremely enlarged kidneys were asymptomatic. Two patients presented vesicoureteric reflux with chronic pyelonephritis. In all cases the kidneys were removed transperitoneally via a transverse or midline incision.

RESULTS

Although no fatal outcome was recorded, three patients required brief hospitalizations in the intensive care unit. The only intraoperative complication was spleen injury in five patients. Surgical postoperative complications developed in nine patients (45%) including: extended drainage and delayed wound healing (n = 4), postoperative hernia (n = 3), prolonged abdominal pain (n = 3), perihepatic hematoma (n = 2), stress duodenal ulceration (n = 1), and subileus (n = 1). Five patients displayed thrombosis of their dialysis access, probably as a consequence of low blood pressure. After surgery 15 patients were placed on the waiting list and 10, successfully transplanted.

CONCLUSION

Simultaneous transabdominal bilateral nephrectomy was associated with a high risk of postoperative complications, but may save the suffering associated with a repeated operation in potential kidney graft recipients who have an indication for bilateral nephrectomy.

Hand-assisted laparoscopic nephrectomy as a minimally invasive option in the treatment of large renal specimens

INTRODUCTION

We describe our experience with hand-assisted laparoscopy (HAL) as an option for the treatment of large renal specimens.

MATERIALS AND METHODS

Between March 2000 and August 2004, 13 patients candidate to nephrectomies due to benign renal conditions with kidneys larger than 20 cm were included in a prospective protocol. Unilateral nephrectomy was performed in cases of hydronephrosis (6 patients) or giant pyonephrosis (4 patients). Bilateral nephrectomy was performed in 3 patients with adult polycystic kidney disease (APKD) with low back pain refractory to clinical treatment previous to kidney transplant. The technique included the introduction of 2 to 3 10 mm ports, manual incision to allow enough space for the surgeon's wrist without a commercial device to keep the pneumoperitoneum. The kidney was empty, preferably extracorporeally, enough to be removed through manual incision. We have assessed operative times, transfusions, complications, conversions, hospital stay and convalescence.

RESULTS

The patients mean age (9 women and 4 men) was 58 years. Mean operating time was 120 +/- 10 min (hydronephrosis), 160 +/- 28 min (pyonephrosis) and 190 +/- 13 min (bilateral surgery for APKD). There was a need for a conversion in 1 case and another patient needed a transfusion due to a lesion in the renal vein; 2 patients had minor complications.

CONCLUSIONS

HAL surgery is a minimally invasive alternative in the treatment of large renal specimens, with or without significant inflammation.

Single-setting bilateral laparoscopic renal surgery: assessment of single-stage procedure

OBJECTIVES

To assess the safety and efficacy of single-setting bilateral laparoscopic renal procedures. The continued advancement of laparoscopic surgical technology and surgeon expertise has allowed increasingly technically challenging procedures to be completed laparoscopically. Little has been reported on patient outcome, morbidity, and mortality of bilateral laparoscopic single-stage procedures.

METHODS

Between May 2000 and February 2004, 13 patients underwent synchronous bilateral renal surgery. Both retroperitoneal (n = 5) and transperitoneal (n = 8) approaches were used. The data were retrospectively analyzed for operative time, morbidity, mortality, and postoperative course.

RESULTS

Bilateral laparoscopic procedures were successfully completed in 11 (85%) of 13 patients. One patient required conversion to an open procedure because of significant adhesions. Another patient with von Hippel-Lindau disease had unexpected extensive pathologic features in each kidney and was therefore treated in a staged fashion. The mean operative time was 5.5 hours (range 4.7 to 8.5). The mean estimated blood loss was 268 mL (range 50 to 950). Patients resumed oral intake and ambulated within 24 hours after surgery. The mean analgesic requirement was 40.5 mg MSO4 equivalents (range 2 to 178). The mean hospital stay was 3.1 days (range 1 to 6). Patients returned to partial activity within the first week and enjoyed full activity at 3 weeks. One intraoperative complication and five postoperative complications occurred in 5 patients.

CONCLUSIONS

Our results have demonstrated that single-setting bilateral laparoscopic renal surgery is safe and can expedite resolution of urologic pathologic findings without increased morbidity. Bilateral single-setting laparoscopic surgery should only be performed if the primary procedure has been completed expeditiously and without complications.

Simultaneous vs. Sequential Laparoscopic Bilateral Native Nephrectomy and Renal Transplantation

We reviewed our experience with simultaneous single incision bilateral native nephrectomy and renal transplantation in 11 patients (Group 1), compared to seven recipients who underwent staged laparoscopic bilateral nephrectomy followed by kidney transplantation (Group 2). Mean age, donor source, sex, cause of ESRD, and specimen size were similar in both groups (P=0.1). All Group 2 patients and 9 of 11 Group 1 patients had autosomal-dominant polycystic kidney disease. Perioperative Group 1 complications included: bowel injury, transplant urine leak, necrotic pancreatitis, delayed bowel movement, and severe shoulder pain secondary to diaphragmatic irritation. Seven (63.6%) Group 1 patients required an additional surgical procedure: midline incisional hernia, repair ureteral fistula, and repair enterocutaneous fistula. One Group 1 patient lost his graft secondary to bowel injury and intra-abdominal sepsis. No major complications, reoperations, or graft loss occurred in Group 2. For simultaneous bilateral native nephrectomy and kidney transplantation, over 60% of patients required an additional surgical procedure. Laparoscopic bilateral nephrectomy followed by kidney transplantation is a safe and feasible alternative.

Volume Progression in Autosomal Dominant Polycystic Kidney Disease: The Major Factor Determining Clinical Outcomes

Autosomal dominant polycystic kidney disease (PKD) is a hereditary condition characterized by the progressive enlargement of innumerable renal cysts that contribute to life-altering morbidity early in the course of the disease. Evidence indicates that the rate of increase in kidney volume can be reliably measured by magnetic resonance or computed tomography imaging, thus providing objective means to judge the effectiveness of therapies that are targeted to the aberrant growth of renal tubules. It is now possible, therefore, to monitor the effectiveness of potential therapies on the signature abnormality in autosomal dominant PKD before irreversible damage has been done by the cysts. Evidence accumulated from human cross-sectional and longitudinal studies and longitudinal studies of PKD models in animals provide strong support for the view that reducing the rate of kidney volume enlargement will ameliorate the late-stage development of renal insufficiency.

Hand-Assisted Laparoscopic Approach to Renal Harvest for Autotransplantation

PURPOSE

To describe a laparoscopic hand-assisted approach to renal autotransplantation that allows both harvest and transplant through the same incision.

PATIENTS AND METHODS

Three patients underwent renal autotransplantation from May 2003 to April 2004, two for loin pain-hematuria syndrome and one for severe ureteral-stricture disease. Two patients underwent autotransplantation on the left and one on the right. Hand-assisted laparoscopy was planned such that inferomedial extension of the hand-port incision would provide adequate exposure of the iliac vessels for autotransplantation.

RESULTS

The average operative time was 240 minutes, the warm ischemia time was 2 minutes 43 seconds, and the hospital stay was 3 days. All three patients had successful graft function by postoperative renal scan with a mean follow-up of 7.1 months.

CONCLUSION

Hand-assisted laparoscopic renal harvest for autotransplantation can be completed with placement of the hand port such that transplantation can be accomplished through the same incision. As many of these patients have had multiple prior retroperitoneal operations, the intracorporeal hand can greatly facilitate these potentially difficult dissections with no added morbidity.

Hand-assisted laparoscopic nephrectomy for inflammatory renal conditions

PURPOSE

Laparoscopic surgery for large renal lesion or kidneys with chronic inflammation has proved to be technically challenging. Hand-assisted laparoscopic surgery might be useful in these complex cases, as it provides surgeons the benefits of tactile feedback, digital retraction, and facilitated dissection of the renal hilar vessels.

PATIENTS AND METHODS

Twenty-two patients undergoing hand-assisted laparoscopic (HAL) nephrectomy for benign conditions were compared with patients who underwent HAL radical nephrectomy during the same period. The demographic data, laterality, operative time, estimated blood loss, conversion rate, length of stay, histopathology findings, morbidity, and mortality were reviewed.

RESULTS

The main indications for surgery were chronic inflammation and xanthogranulomatous pyelonephritis. Twenty patients had unilateral nephrectomy (10 each on the right and left), and two patients had bilateral nephrectomy. The mean operative times for unilateral and bilateral nephrectomy were 163 minutes (range 55-261 minutes) and 265 minutes (range, 238-291 minutes), respectively. Nine patients (45%) with inflammation had complications (15% major and 30% minor). The mean length of hospitalization for patients undergoing HAL nephrectomy was 7.2 days (range 2-35 days). The patients with inflammatory pathology had longer mean operative times, higher estimated blood loss, longer hospital stay, and higher morbidity than patients undergoing radical nephrectomy.

CONCLUSION

Compared with standard laparoscopy, the hand-assisted approach has been reported to reduce operative times and increase safety. The advantages of minimally invasive surgery, such as reduced analgesia, shorter hospital stay, and faster return to normal activity, appear to be similar to those in patients undergoing a pure laparoscopic nephrectomy. Compared with radical nephrectomy for renal tumor, HAL simple nephrectomy can often be more challenging and associated with greater morbidity. For both the community urologist as well as an experienced laparoscopist, this approach is useful in handling these challenging cases.

Hand-assisted laparoscopy for multiple organ removal

Simultaneous removal of multiple organs is a situation seldom encountered by the urologist but may be needed in patients with adult polycystic kidney disease or malignancies or infectious processes involving more than one organ. Historically, open surgery has been considered necessary to gain adequate exposure. However, hand-assisted laparoscopic surgery is suitable for many of these patients. The hand-port and trocar positions are chosen according to the laparoscopic experience of the surgeon and depend on whether an ambidextrous or nondominant-hand procedure is planned. Several techniques are described, with a focus on bilateral nephrectomy.

Bilateral purely laparoscopic nephrectomy for renal masses using five ports without repositioning: a case report

BACKGROUND AND PURPOSE

Bilateral nephrectomy is an infrequently performed procedure. The indications include bilateral masses too large for nephron-sparing surgery, recalcitrant hypertension in dialysis patients, pain, infection, reflux, or large symptomatic polycystic kidneys. Bilateral pretransplant purely laparoscopic nephrectomy for bilateral renal masses has not been reported previously. We present our experience with this procedure using five transabdominal trocars without having to reposition the patient.

METHODS

We employed a five-port technique in a middle-aged woman with end-stage renal disease who presented with an infected peritoneal dialysis catheter. On abdominal CT, she had bilateral enhancing renal masses. Six weeks after removal of the catheter, she underwent bilateral transperitoneal laparoscopic nephrectomy. The technique is described, and recommendations are made regarding potential obstacles.

RESULTS

The procedure was performed in 185 minutes, and the total hospital time was 41 hours. The estimated blood loss was 50 mL. Final pathology examination revealed a 5.5-cm right renal-cell carcinoma stage T1N0M0 and left hydronephrosis, atrophy, nephrosclerosis, and thick-walled renal cysts without malignancy. On 3-month follow-up she is well, without complaints.

CONCLUSION

Bilateral pretransplant purely laparoscopic nephrectomy can be performed without significant repositioning, redraping, and resterilization. In this case, operative time and cosmesis were acceptable, and surgical morbidity was low.

Hand-Assisted Laparoscopic Nephrectomy in Autosomal Dominant Polycystic Kidney Disease

BACKGROUND

Among patients with renal insufficiency secondary to autosomal dominant polycystic kidney disease (ADPKD), the onset of refractory urinary infection, hypertension, pain, or hematuria often necessitates a nephrectomy. However, the huge size of these kidneys makes a standard laparoscopic approach difficult, and the increased fragility of these patients makes an open nephrectomy risky. A compromise position has been found in the realm of hand-assisted laparoscopic techniques, especially for patients in need of a bilateral nephrectomy.

TECHNIQUE

Hand-assisted laparoscopic nephrectomy (HALN) is performed via a hand-assist device placed in the midline. A subxiphoid midline port and a midclavicular subcostal port are placed on the ipsilateral side. The right hand is inserted for left nephrectomy and the left hand for a right nephrectomy. The laparoscope is introduced into the subxiphoid port, and the surgeon's primary working instrument is passed via the midclavicular port. Occasionally, it is helpful to place a 5-mm subcostal port in the midaxillary line to aid in retracting the kidney. Once the kidney is devascularized, it is removed via the 7- to 8-cm hand-assist incision; drainage of cysts may be necessary during extraction to reduce the kidney size so that it can be withdrawn. If a bilateral approach is to be done, then after the first nephrectomy, the lateral 5-mm port is closed, and the table is rolled such that the contralateral side is elevated about 30 degrees to 45 degrees; a subcostal midclavicular 12-mm port is placed, and, if needed, a 5-mm port is inserted subcostally in the midaxillary line for renal retraction.

RESULTS

Seven bilateral hand-assisted laparoscopic nephrectomy cases have been reported. In two reports, the mean operating times were 4.8 and 5.5 hours. The mean estimated blood loss was <350 mL.

CONCLUSION

The hand-assisted laparoscopic approach makes both unilateral and bilateral nephrectomy feasible in ADPKD patients with acceptable morbidity.

Trocar Arrangement for HALS

The appropriate position of the hand-access device and trocars for hand-assisted laparoscopic surgery depends on several factors, including the surgeon's preference, physical stature, and handedness; the patient's anatomy; and the type of procedure being performed. This article reviews the options, including measures for special circumstances such as patient obesity.

Hand-assisted laparoscopic resection of the massive autosomal dominant polycystic kidney

Laparoscopic nephrectomy provides many advantages over open nephrectomy, including pain reduction, hospitalization, and superior cosmesis. However, the bulkiness of massively enlarged polycystic kidneys may preclude access to the renal hilum and therefore prevent safe ligation and division of the renal vascular supply. We describe a hand-assisted technique that facilitates the resection of the massively enlarged kidney.

Pretransplant native nephrectomy in patients with end-stage renal failure: assessment of the role of laparoscopy

OBJECTIVES

To evaluate the outcome and morbidity of laparoscopic nephrectomy in patients with end-stage renal disease.

METHODS

Between August 1991 and September 2001, 64 laparoscopic nephrectomies were carried out for the native kidneys of 62 patients with end-stage renal failure. The procedures were performed in preparation for renal transplantation. The indications were vesicoureteral reflux with persistent or recurrent urinary tract infection in 26 renal units, uncontrolled hypertension in 15, chronic pyelonephritis or hydronephrosis with urinary tract infection in 8, renal calculi in 13, heavy proteinuria in 1, and small renal tumor in 1. The left side was removed in 52 procedures and the right side was removed in 12. Forty-eight and 16 renal units were removed through the retroperitoneal and transperitoneal approach, respectively.

RESULTS

Sixty procedures were successfully performed (94%). Four patients required open exploration (6%). Four major complications were recorded: pneumothorax in 1, large hematoma in 1, colonic injury in 1, and bleeding in 1. No mortality related to the procedures or their complications occurred. The patients received allograft transplantation shortly after the procedure, with a mean of 26 days. Both transperitoneal and retroperitoneal approaches were effectively used with satisfactory outcome.

CONCLUSIONS

Laparoscopy should be considered as the procedure of choice for pretransplant nephrectomy. The high success rate, low morbidity, early recovery, and short duration between nephrectomy and transplantation all are considered as real advantages for this patient population.

Laparoscopic bilateral hand-assisted nephrectomy: end-stage renal disease from tuberculosis, an unusual indication for nephrectomy before transplantation

The purpose of the study was to sterilize renal tuberculous foci in a pretransplantation patient with a laparoscopic hand-assisted approach and to verify the feasibility of bilateral nephrectomy for this indication. This case report is the first description of hand-assisted laparoscopic bilateral nephrectomy for this pathologic condition. The 33-year-old patient had end-stage renal disease from renal tuberculosis. A commercially available hand-assistance device was used through a midline 8-cm supraumbilical incision and with four ports. The procedure was successfully completed. The total operative time was 3 hours and 40 minutes. Estimated blood loss was 250 mL. The postoperative course was uneventful, and clinical follow-up at 3 weeks revealed a successful outcome. Hand-assisted bilateral laparoscopic nephrectomy in patients with chronic renal failure from tuberculosis represents a viable option because it is feasible and effective. The hand-assisted approach increases the safety of the procedure while retaining all the advantages of minimally invasive surgery.

Hand-assisted urological laparoscopy

Hand-assisted laparoscopy has been successfully applied to various applications within the field of urology. Many authors have proved the safety and efficacy of this technique, as well as demonstrating improved patient recovery for such procedures as radical nephrectomy, radical nephroureterectomy and donor nephrectomy. The recent literature regarding this topic is reviewed and evaluated here.

Patient positioning and port placement for bilateral hand-assisted laparoscopic nephrectomy

Hand-assisted laparoscopic nephrectomy is an alternative to laparoscopic nephrectomy. We describe our method for triangular port placement and patient positioning during bilateral hand-assisted laparoscopic nephrectomy. This method does not require intraoperative patient repositioning and may decrease the overall operative time while enhancing patient safety.

Bilateral hand-assisted laparoscopic nephrectomy for autosomal dominant polycystic kidney disease using a single midline HandPort incision

OBJECTIVES

To present one of the first known series of bilateral, transperitoneal laparoscopic nephrectomy for autosomal dominant polycystic kidney disease using a hand-assisted technique by way of a single, midline HandPort incision. Synchronous, bilateral nephrectomy for autosomal dominant polycystic kidney disease is an infrequently performed procedure, with only a few reports using laparoscopy.

METHODS

We retrospectively reviewed the charts of 4 patients undergoing bilateral hand-assisted laparoscopic nephrectomy for symptomatic autosomal dominant polycystic kidney disease between June 2000 and January 2001. Follow-up consisted of chart review and telephone survey.

RESULTS

All 4 patients underwent successful bilateral hand-assisted laparoscopic nephrectomy, with a mean operative time of 286 minutes. This included 1 patient who underwent simultaneous laparoscopic marsupialization of symptomatic hepatic cysts. The average size of the polycystic kidneys removed was 1582 g. Complications included acute tubular necrosis of a renal allograft in 1 patient that resolved spontaneously and retained retroperitoneal cystic fluid that required percutaneous drainage in another patient. All patients did well postoperatively, with complete resolution of their presenting symptoms. Those with renal allografts had stable function at the last follow-up visit.

CONCLUSIONS

Bilateral hand-assisted laparoscopic nephrectomy using a single HandPort incision is a feasible alternative for the removal of symptomatic polycystic kidneys. It offers the advantage of easier identification and control of hilar structures that are often obscured by the distorted renal anatomy. In addition, it allows the simultaneous performance of other intra-abdominal procedures.