Open-renal biopsy in uremic patient

Retroperitoneal laparoscopic renal biopsy: an 8 year experience at a single centre

PURPOSE

To present our experience and outcome of consecutive laparoscopic renal biopsy (LRB) in a series of Chinese patients over an 8 year period.

METHODS

Between January 1, 2013, and December 31, 2020, 104 patients (M/F 71/33, age 43.6 ± 16.0 years) were enrolled. All patients underwent LRB for various indications, e.g., dialysis dependence (33.7%), serum levels of creatinine ≥ 442 μmol/L (20.2%), morbid obesity (18.3%), uncontrolled severe hypertension (14.4%), aberrant renal anatomy (5.8%), solitary kidney (2.9%), deaf-mutes (2.9%), failed percutaneous biopsy (1.0%) and patient choice (1.0%). The kidney was approached via the laparoscopic retroperitoneal route using a three-port technique. Then, 16-gauge true-cut needle biopsy was performed and haemostasis was achieved by compression. Topical collagen mesh was used if necessary.

RESULTS

Renal tissue was obtained in all cases. The operative time and amount of blood loss were significantly (P < 0.05) lower in 2017-2020 than 2013-2016 [42.6 ± 1.5 min and 9.6 ± 0.7 mL, respectively (n = 61) vs. 51.2 ± 1.3 min and 14.4 ± 0.9 mL, respectively (n = 43)], while the hospital stay was not significantly different between the two periods. The rate of tissue adequacy and median number of glomeruli were significantly higher in 2017-2020 than 2013-2016 [100% and 52 (IQR 24-94), respectively vs. 93% and 35 (IQR 6-98), respectively). Two postoperative complications occurred in the first 4 years: disseminated intravascular coagulation (DIC) during the operation and injury at the hilum of the kidney (n = 1 each). The renal pathological diagnoses were also complex: 70.2% of the cases were independent pathological types, including IgA nephropathy (IgAN) (13.5%), Henoch-Schönlein purpura nephritis (HSPN) (2.9%), focal segmental glomerulosclerosis (FSGS) (9.6%), membranous glomerulonephritis (MN) (1.9%), lupus nephritis (LN) (3.8%), crescentic glomerulonephritis (CreGN) (7.7%), diabetic nephropathy (DN) (10.6%), tubulointerstitial nephritis (TIN) (11.5%) and malignant hypertensive nephropathy (MHTN) (8.7%). However, the rates of combinations of two and three pathological types were 25.0% and 4.8%, respectively.

CONCLUSION

Retroperitoneal LRB is a safe, reliable, minimally invasive alternative for patients in whom PRB in not feasible. As a helpful supplement to PRB, it may be necessary to use this technique more often in the future.

Open renal biopsy: comorbidities and complications in a contemporary series

STUDY TYPE

Therapy (case series) Level of Evidence 4.

OBJECTIVE

To report the indications and outcomes of a contemporary series of patients with contraindications to percutaneous renal biopsies (PRBs) who had an operative RB (ORB), as although ORB is a relatively infrequent procedure, it remains an important and underreported operation.

PATIENTS AND METHODS

In a retrospective review of patients who had an ORB we examined comorbidities, indications, and 30-day morbidity and mortality. Preoperative comorbidities were stratified according to the Charlson comorbidity index.

RESULTS

In all, 115 patients had ORB between 1991 and 2006 (mean age 48 years, range 18-83); 60% of the patients were American Society of Anesthesiologists class >or=3. The median Charlson comorbidity index score was 3, with a score of 0 in 20.9%, 1-2 in 27.8%, 3-4 in 30.4% and >or=5 in 20.9% of patients. Indications for an ORB included morbid obesity, failed PRB, coagulopathy, and solitary kidney. In all, 47.8% of patients had a serum creatinine level of <3.0 mg/dL, 34.8% of >3.0 mg/dL and 17.4% were dialysis-dependent. There were 43 complications in 36 patients. The mortality rate after surgery was 0.8%. There were eight major complications in seven patients (6.1%) including cardiac arrest, stroke, sepsis, reoperation and re-intubation. There were minor complications 34 times in 31 patients (27%), the most common being wound infection, pneumonia, intraoperative transfusion of >2 units, arrhythmia, postoperative retroperitoneal bleed, and seep vein thrombosis.

CONCLUSIONS

This study shows that there are significant comorbidities in patients referred to urologists for an ORB. With a mortality rate of 0.8% and major and minor complication rates of 6.1% and 27%, respectively, the ORB, while infrequent, carries a significant risk in this population that should be included in preoperative decision making and used for patient counselling.

Retroperitoneoscopic renal biopsy in children

OBJECTIVE

We present our experience in a series of 17 consecutive pediatric patients submitted to retroperitoneal laparoscopic renal biopsy.

MATERIALS AND METHODS

Retroperitoneal laparoscopic renal biopsy (LRB) was performed in 5 boys and 12 girls. Mean age was 8.1 years and age range from 2 to 12. Two or three trocars were used to expose the inferior pole of the kidney, remove enough cortical parenchymal specimen and fulgurate the biopsy site. Assessment included surgical time, estimated blood loss, hospitalization period, analgesia requirements, complications and number of glomeruli present in the specimen.

RESULTS

LRB was successfully performed in all 15 patients (88%). In two cases, LRB was not possible to be performed. One patient was converted to a transperitoneal laparoscopy due to tear in the peritoneum. The other patient had had previous abdominal surgery and, during retroperitoneal balloon dilation, the peritoneum was opened and the open biopsy was performed. A third patient had postoperatively a perirenal hematoma, which was solved spontaneously. Complication rate was 17.6% (3/17 cases). Mean operative time was 65 minutes, while mean estimated blood loss was 52 mL, mean hospital stay was 2.2 days and mean analgesic requirement was 100 mg of tramadol. The mean number of glomeruli present in the specimen was 60.

CONCLUSION

Retroperitoneal laparoscopic renal biopsy in children is a simple, safe. Bleeding is still the most common complication. However, direct vision usually allows a safe control of this drawback. In our institution, laparoscopic approach is the chosen procedure in pediatric patients older than one - year - old.

Laparoscopic renal biopsy in obese children

Percutaneous kidney biopsy is routinely used to obtain renal tissue for histological examination. It is usually successful and has very few contraindications. We describe two children with clinical obesity in whom the percutaneous approach failed to yield renal tissue for histology. They underwent successful laparoscopic kidney biopsies that yielded adequate renal tissue for diagnosis, although the first attempt in one patient yielded renal medulla necessitating a repeat biopsy. We recommend that laparoscopic kidney biopsies should be considered in obese children when percutaneous kidney biopsies are considered impossible.

Retroperitoneal laparoscopy for renal biopsy in children

PURPOSE

We report our experience with the retroperitoneal laparoscopic approach for treating pediatric patients and when the percutaneous needle approach is not possible due to uncontrolled hypertension, bleeding disorders, anti-clotting medications and anatomical abnormalities.

MATERIALS AND METHODS

Retroperitoneal laparoscopic renal biopsy was performed in 20 patients 2 to 18 years old (mean age 9.7) during a 16-month period. At the same time 53 percutaneous needle biopsies and 1 open biopsy were performed. The child is in a flank position, and 2 trocars are used via a direct vision approach. The first trocar is 12 mm. in diameter and positioned on the posterior axillary line, and the second trocar is 5 mm. in diameter and is entered 4 cm. anteriorly. Gentle dissection is done to free the lower pole of the selected kidney, biopsy forceps are used to grasp the specimen under direct vision and the biopsy site is fulgurated using bipolar electrocautery.

RESULTS

Biopsy was performed successfully in all cases except 1, which was converted to an open procedure. Mean operative time was 40 minutes, blood loss was minimal and mean hospital stay was 1.2 days postoperatively. No pain medication was required postoperatively, and all patients returned to their usual activities within 3 to 5 days. A minor intraoperative complication, which was a peritoneal tear with no postoperative sequelae, occurred in 1 case.

CONCLUSIONS

The retroperitoneal laparoscopic technique is simple and safe, and does not require extensive laparoscopic experience. We believe that this approach is reliable, and has less morbidity and several advantages compared to open surgery. It should be selected as the first choice for treating pediatric patients when percutaneous needle renal biopsy is contraindicated.

Laparoscopic renal biopsy

BACKGROUND

Renal biopsy continues to be a pivotal tool and frequently indispensable diagnostic procedure in the clinical assessment of proteinuria and or unexplained renal disease. Laparoscopic renal biopsy has recently been reported as an alternative to open renal biopsy.

METHODS

Thirty-two patients who had proteinuria and/or renal insufficiency underwent laparoscopic renal biopsy at our center. The indications for biopsy included failed percutaneous biopsy (N = 3), morbid obesity (14), solitary kidney (5), chronic anticoagulation/coagulopathy (6), religious consideration (refusal of potential blood transfusion) (2), multiple bilateral renal cysts and body habitus (1 case each). The kidney was approached via a laparoscopic retroperitoneal route (retroperitoneoscopy) using a two port technique. The lower pole of the kidney was localized using blunt dissection, laparoscopic cup biopsies were performed, and hemostasis was achieved using standard techniques.

RESULTS

All biopsies were successfully completed laparoscopically with sufficient tissue obtained for histopathological diagnosis in all cases. Mean estimated blood loss was 25.9 ml (range 5 to 100). None of the patients required parenteral narcotics during the perioperative period. Operative time ranged from 0.8 to 3.0 hours (mean 1.5). Mean hospital stay was 1.7 days (range 0 to 7). Sixteen patients were treated as outpatients. Patients returned to normal activity at a mean of 1.7 weeks (range 0.3 to 3.0) postoperatively. In one patient, the spleen was inadvertently biopsied without consequence. An additional patient developed a postoperative 300 cc perinephric hematoma that resolved without the need for intervention. One postoperative mortality occurred on postoperative day seven secondary to a perforated peptic ulcer in a patient undergoing high-dose steroid therapy for lupus nephritis.

CONCLUSION

Laparoscopic renal biopsy is a safe, reliable, minimally invasive alternative to open renal biopsy for patients in whom a closed percutaneous approach is either a relative or absolute contraindication, which can be performed on an outpatient basis.

Laparoscopically assisted percutaneous renal biopsy

We performed laparoscopically assisted percutaneous renal biopsy on 4 patients with azotemia or renal dysfunction who were believed to be unsuitable candidates for percutaneous renal biopsy. Tissue adequate for diagnosis was obtained in all 4 cases. Complications included subcutaneous emphysema in 1 patient and a small splenic capsular tear in 1, which was managed laparoscopically and did not require transfusion. Bleeding from the renal biopsy occurred in 1 patient and was easily managed laparoscopically. We recommend laparoscopically assisted percutaneous renal biopsy as an alternative method of renal biopsy in patients who can tolerate general anesthesia and who are not candidates for percutaneous renal biopsy.

Percutaneous renal biopsy of the solitary kidney: a contraindication?

We recently were presented with a patient from the nephrology service, with the request to perform open renal biopsy because of a solitary functioning kidney. We performed the open biopsy and the patient subsequently had a wound infection, leading us to question the recommendation in the literature stating that a solitary kidney is an absolute contraindication for percutaneous renal biopsy. In a review of the literature from 1951 to 1990, a total of 19,459 percutaneous renal biopsies has been reported with an overall complication rate of 2.1 to 10.8%, the majority (90%) of which did not require definitive treatment. Only 13 nephrectomies (0.06%) were required secondary to complications. The overall mortality rate was 0.08%. We reviewed 157 percutaneous renal biopsies done at this institution from 1985 to 1990 with a minor complication rate of only 5% and no major complications or loss of kidney function. The mortality rate was 0. Based on our study and a review of the literature, both showing an extremely small percentage of permanent loss of kidney function or mortality, we propose that a solitary kidney no longer be recommended as an absolute contraindication to percutaneous renal biopsy.

Value of renal biopsy in chronic renal failure

A total of 120 patients with chronic renal failure secondary to parenchymatous kidney disease were biopsied. Percutaneous approach was tried and open technique was employed when there was contraindication to or failure of the percutaneous technique. In 72 cases the histopathologic lesions were identified, in 30 cases it was not possible to identify them and in 18 cases there was no sufficient kidney tissue. The diagnosis was very critical in at least 10 cases: there were 3 cases of primary oxalosis, one case of haemolytic uraemic syndrome, one case of necrotizing glomerulonephritis, one case of Wagner's granulomatosis, 3 cases of focal segmental glomerulosclerosis and one case of Fabry's disease. All but one of these were not diagnosed clinically. There was no patient mortality, and morbidity was significantly higher after open approach. We concluded that kidney biopsy in patients with chronic renal failure is mandatory especially if they are going to be transplanted and it is relatively safe especially when the percutaneous technique is employed.

Acute renal failure due to perirenal hematoma complicating open renal biopsy

Diminished renal concentration and excretion of intravenous radiographic contrast medium are cardinal findings in perirenal hematoma. However, despite a high incidence of perirenal hematoma after renal biopsy acute renal failure has not been described in this setting. A case of oliguric acute renal failure owing to perirenal hematoma after open biopsy of a solitary kidney is reported.

Role of renal biopsy in end stage renal failure

The role of renal biopsy in 46 patients with end stage renal failure was assessed. Renal tissue was obtained by open renal biopsy in 24 patients, by needle biopsy in 5, and at bilateral nephrectomy in 17. In 4 patients the renal biopsy specimens showed advanced changes that could only be diagnosed as "end stage kidney". In 42 patients (91 per cent), a precise renal diagnosis was made. In 20 patients (43 per cent) the prebiopsy clinical impression differed from the histologic diagnosis. In the 29 patients undergoing renal biopsy, minor postoperative morbidity occurred in 5. We conclude that a renal biopsy in patients with end stage renal failure will result in a change in clinical diagnosis in a significant number of patients and can be performed with low morbidity.

Open renal biopsy technique: results in 202 patients

Two hundred five cases of open renal biopsy using a muscle-splitting technique have been performed over the past seven years. Eighty-seven per cent were done under local anesthesia. Tissue for routine histology, immunofluorescence staining and electromicroscopy were obtained in all cases. Morbidity was low, and there were no deaths attributed to the procedure.

A comparative study of open surgical and percutaneous renal biopsies

Percutaneous renal biopsy was performed on 171 patients during the same interval as an open surgical biopsy was done on 100 patients in the same hospital. Patients who underwent an open biopsy had more severe renal dysfunction and hypertension than those who had a percutaneous biopsy. Tissue adequate for diagnosis was obtained in 100 per cent of the open biopsies. The kidney was reached in 88 per cent of all percutaneous biopsies with tissue adequate for diagnosis in 82.5 per cent. Of 87 patients biopsied with image-amplification fluoroscopy renal tissue was obtained in 97 per cent with tissue adequate for diagnosis in 92 per cent. No nephrectomies were done and no deaths occurred in either group. Our complications and yield by percutaneous biopsy compared favorably to those of other series. Further, open biopsy in a high risk population was associated with a high yield of tissue adequate for diagnosis with no increase in complications. Procurement of renal tissue need rarely be denied a patient if a biopsy is clinically indicated.

Renal arteriovenous fistulas

A review of the literature reveals that aggressive treatment of symptomatic intrarenal arteriovenous fistulas, whether by surgical or radiologic techniques, is generally indicated. The exception is those fistulas which result from closed renal biopsy since these usually heal spontaneously. The ultimate goal of any form of therapy is the maximal preservation of renal tissue. Methods of treatment are discussed, and a review of classification, etiology, incidence, symptoms, physiologic consequences, and means of diagnosis is given. A case of post-traumatic intrarenal arteriovenous fistula with ipsilaterally elevated renal vein renin and hypertension, cured by partial nephrectomy, is presented.