Laparoscopic management of symptomatic simple renal cysts

Radiologically guided percutaneous aspiration and sclerotherapy of symptomatic simple renal cysts: a systematic review of outcomes

Simple renal cysts are common benign lesions of the kidney with up to 4% of patients developing symptoms necessitating intervention including pain and haematuria. We conducted a systematic review of the literature to determine the efficacy and safety of aspiration-sclerotherapy of symptomatic simple renal cysts. A systematic review using Cochrane guidelines was conducted on published literature from 1990 to 2020. RCTs, cohort studies and case series meeting the inclusion criteria were reviewed and cumulative analysis of outcomes was performed. A total of 4071 patients from 57 studies underwent aspiration ± sclerotherapy for their simple renal cysts. 87.7% of patients who had aspiration with sclerotherapy demonstrated 'treatment success' with a >50% reduction in cyst size and complete resolution of symptoms. 453 minor, transient complications occurred (11.2%) whilst a major complication rate of less than 0.1% (4 patients) was reported. Pooled analysis of all available current literature demonstrates that aspiration-sclerotherapy is a safe and effective first-line therapy for symptomatic simple renal cysts. Although we are unable to compare those undergoing aspiration alone to aspiration-sclerotherapy, it is evident the use of a sclerosing agent is integral to treatment success; however, the optimum agent, volume, injection frequency, and dwelling time are yet to be defined. Cyst size should be considered when discussing treatment options; however, we conclude it reasonable for aspiration-sclerotherapy to be used in the first instance in all cases of symptomatic simple renal cysts. Furthermore, we propose definitions of treatment outcome measures in order to allow direct comparative analysis across future studies.

Percutaneous nephrostomic decortication: a microinvasive surgery for posterior renal cyst

To assess the safety, feasibility, and efficacy of a modified process we developed in order to perform decortication surgeries for simple renal cysts through a percutaneous approach, 18 patients with simple renal cysts larger than 5 cm were treated with our new technique, from November 2016 to January 2019. All of the cysts were evaluated with ultrasonography and contrast-enhanced computed tomography. The Surgical procedure: as the standard mini-Percutaneous Nephrostomy procedure, a puncture was made directly into the cyst through the cyst roof under ultrasound guidance. After the inner cyst wall examination, the sheath was then retracted to just outside the cyst roof. The sheath together with the scope was used to detach the roof from the perirenal fat, after which the cyst roof was resected using a laser. A drain tube was left in the retroperitoneal space for 1-2 days. Subsequently, all patients were discharged 1 to 2 days post-surgery. Skin incision was less than 1 cm. No major complication was observed. The follow-up time ranges from 14 to 37 months. One case had an incompletely resected cyst with the cyst volume being decreased by more than 60%. This patient didn't receive any additional treatments during his follow-up. For all the other patients, the cysts had completely disappeared and no relapse had occurred. In conclusion, in the selected patients with a simple posterior renal cyst, our new technique is a safe and an effective option. It is also considered the least invasive decortication surgery for posterior renal cyst.

Retroperitoneal laparoendoscopic single-site approach for renal cyst decortication - first experience and a review of literature

Laparoendoscopic single-site (LESS) approach has been successfully employed for a number of urologic procedures. The retroperitoneal approach further limits the working space and instrument movement during LESS surgery, but has the advantage of a faster post-operative recovery and lower complications rate. We present our first experience using retroperitoneal LESS approach for a renal cyst decortication in a 40-year-old patient. The operative time was 40 minutes, the blood loss was minimal and we did not encounter significant conflicts between the instruments. The patient was discharged 2 days after the procedure and returned to full normal activity within one week. We consider that the retroperitoneal LESS approach is feasible for upper tract urologic surgery. Pre-bent instruments might further improve surgical gestures and extend the indications for more complex procedures. Nevertheless, the advent of reusable devices is expected to increase the cost-effectiveness of LESS and expand its use.

The efficacy of retroperitoneal laparoscopic deroofing of simple renal cyst with perirenal fat tissue wadding technique: A retrospective study

Treatment options for simple renal cyst (SRC) include open surgery, laparoscopy with decortication, or percutaneous aspiration with or without sclerotherapy. Though laparoscopic unroofing achieves better results than percutaneous sclerotherapy, the reported recurrence rate is still up to 19%. Thus, it is necessary to find methods to reduce the recurrence rate.To investigate whether the perirenal pedicled fat tissue wadding technique during retroperitoneal laproscopic deroofing (RLD) of SRC affects the incidence of recurrence.A retrospective analysis was carried out on clinical data of 254 patients with SRC treated by RLD in our hospital from 2008 to 2016. Among these patients,119 had a simple retroperitoneal deroofing (SRD) and 135 received a retroperitoneoscopic deroofing with wadding of the cyst using perirenal fat tissue (RDCW). The recurrence rate and variables, as well as perioperative complications, were compared. To further explore the potential variables influencing cyst recurrence rate, univariate and multivariate regression analyses were applied.A total of 251 patients were included in the analysis. The operation was successfully completed laparoscopically in all cases with no conversion to open surgery. No mortality or significant complication occurred in both groups. After a median follow-up of 38.67 months, we noted 41 recurrences. According to the univariate and multivariate regression analyses, patients managed with the wadding technique had superior recurrence-free survival (RFS), compared with patients in SRD group (log-rank P = .03 and P = .04, respectively). Moreover, patients with single renal cyst had a lower recurrence rate, compared with patients with multiple renal cysts (log-rank P < .01). Regarding the operation time, blood loss, and hospital stay, no statistically significant difference was found between 2 groups (P values .13, .30, and .75, respectively). However, less postoperative drainage and shorter postoperative interval until tube removal (P = .04) were observed in RDCW group.The perirenal pedicled fat tissue wadding technique can decrease the cyst recurrence rate and RCDW represents an effective and safe treatment option in the management of renal cysts.

Management of renal cysts

Background and Objectives:

Renal cysts have a high prevalence in the general population, and their estimated incidence increases with age. Renal cyst aspiration (usually with sclerotherapy) or open/laparoscopic decortication is a generally effective and safe method in the treatment of symptomatic simple renal cysts. The success rates of laparoscopic decortication and percutaneous aspiration-sclerotherapy were compared to assist in the decision making for the procedure.

Methods:

A total of 184 patients with symptomatic simple renal cysts were treated with either laparoscopic decortication in 149 cases or percutaneous aspiration-sclerotherapy in 35 cases. The follow-up period was approximately 35 months, and the symptomatic and radiologic success rates of the 2 techniques were compared retrospectively.

Results:

Laparoscopic decortication was found to have high success rates, a low recurrence rate, and minimal morbidity. Percutaneous aspiration-sclerotherapy is an outpatient procedure with a minimally higher recurrence rate.

Conclusion:

When a symptomatic cyst is encountered and treatment of the cyst is indicated, laparoscopic decortication is a more efficient method that offers better results than percutaneous aspiration-sclerotherapy.

The laparoscopic management of symptomatic renal cysts: A single-centre experience

Objectives

To present our experience of treating symptomatic renal cysts by different techniques of laparoscopic decortication, as there are many treatment options for such cysts, each of them with advantages and drawbacks.

Patients and methods

Between January 2002 and December 2012, 51 patients underwent laparoscopic renal-cyst decortication; 15 of them had recurrent cysts after percutaneous aspiration. A retroperitoneal approach was adopted in 44 cases, transperitoneal in four and laparo-endoscopic single-site surgery (LESS) cyst decortication in three (two of them had bilateral renal cyst decortications in the same session). All patients were diagnosed by ultrasonography and computed tomography to determine the Bosniak classification of the cyst. Pain and cyst recurrence were assessed during the follow-up.

Results

All procedures were completed successfully, with no major intraoperative complications. The mean (range) operative duration was 56 (35–125) min, affected by the site and number of cysts unroofed. All patients were symptom-free except one, who had a recurrent large cyst, anteriorly located, and who underwent open cyst decortication.

Conclusions

Laparoscopic decortication of symptomatic renal cysts should be the standard of care, especially after failed percutaneous aspiration or decortication. LESS cyst decortication is a promising technique, especially with bilateral pathology. It is feasible with conventional laparoscopic instruments and gives a better cosmetic outcome.

Complications of sporadic, hereditary, and acquired renal cysts: cross-sectional imaging findings

Commonly encountered in the general adult and elderly population, in most cases simple renal cysts are confidently diagnosed on imaging studies and do not require further workup or treatment. However, large or growing renal cysts sometimes cause symptoms or signs such as hypertension, palpable mass, flank or abdominal pain, obstructive uropathy, and hematuria, which may indicate the need for minimally invasive percutaneous or laparoscopic treatment. Furthermore, severe complications such as cystic hemorrhage, rupture, or superinfection may occur, particularly in patients with polycystic renal disorders, either hereditary (namely adult polycystic kidney diseases) or acquired in chronic renal failure. This pictorial essay reviews and discusses the cross-sectional imaging appearances of symptomatic and complicated sporadic, hereditary, and acquired renal cysts. Early cross-sectional imaging with multidetector computed tomography or magnetic resonance imaging or both, including contrast enhancement unless contraindicated by renal dysfunction, is warranted to investigate clinical and laboratory signs suggesting retroperitoneal hemorrhage or infection in patients with pre-existent renal cysts, particularly if large, multiple, or hereditary.

Laparoscopic decortication of hilar renal cysts using LigaSure

Background and Objectives:

In this study, we evaluated the safety and efficacy of using the LigaSure sealing system (Valleylab, Boulder, Colorado) for laparoscopic decortication of symptomatic hilar renal cysts.

Methods:

Seventeen patients underwent laparoscopic decortication of hilar renal cysts with the LigaSure system. Our study included only symptomatic, Bosniak type 1, simple and symptomatic renal cysts. The operative route, transperitoneal or retroperitoneal, was planned according to the location confirmed by computed tomography. The patients' symptoms were preoperatively and postoperatively evaluated by the Wong-Baker visual pain scale. Operative measures and radiologic outcomes were prospectively evaluated.

Results:

The mean age of the patients was 56.4 years, and the mean follow-up period was 12.5 months. Preoperative computed tomography showed only a single cyst in 15 patients (88.2%) and showed two separate cysts in 2 cases (11.8%). The cysts were located in the perihilar region close to the vascular structure in all patients. A transperitoneal approach was used in 9 patients, and a retroperitoneal approach was used in 8 patients. The mean operative time and hospitalization time were 56.4 minutes and 1.2 days, respectively. Minor complications were observed in 3 patients. Symptomatic and radiologic success rates of 94.2% and 100%, respectively, were achieved.

Conclusion:

Laparoscopic decortication of symptomatic hilar renal cysts—first reported in the literature in this study—using the LigaSure sealing system is feasible, effective, and safe, even if the cyst is located in the perihilar area.

Surgical management of renal cystic disease

The kidney is one of the most common sites for cyst in the body (prevalence about 5%). Symptomatic or incidental cyst needs to be characterized further based on Bosniak classification as simple (Bosniak type I & II) or complex (Bosniak type III & IV) cysts with respect to risk of malignancy or other effects on the kidney. The management of simple cysts is entirely for its symptoms or complications (eg, hemorrhage, infection, hydronephrosis, and hypertension). Percutaneous aspiration alone or with sclerotherapy often is the first-line treatment. Surgical decortication generally is reserved for recurrent or very large symptomatic cysts. Laparoscopic surgery is highly efficacious and is associated with high satisfaction rates with minimal morbidity. Retroperitoneal approach is generally preferred, especially in infected or hydatid renal cyst to avoid spillage or contamination of virgin peritoneal cavity. Cyst decortication seems to be an appropriate indication for newer-emerging single-port laparoscopic approaches such as natural orifice transluminal endoscopic surgery, single-incision laparoscopic surgery, or laparoendoscopic single-site surgery. Where available, robot-assisted surgical management can supplant pure laparoscopic management for complex cysts, hydatid cyst, peripelvic cyst, and autosomal dominant polycystic kidney disease without any outstanding benefits, but with added cost, when robot is used.

Laparoscopic decortication of symptomatic simple renal cyst using conventional monopolar device

In our study, we assessed the efficacy, safety, and feasibility of laparoscopic decortication of symptomatic simple renal cysts using conventional monopolar device. Long-term symptomatic and radiological results of 15 patients who underwent laparoscopic renal symptomatic simple cyst decortication, which was performed by conventional monopolar device, were retrospectively reviewed. The mean age of the patients was 49.7 years. There were nine male and six female patients. Their presenting symptoms were lumber pain in 93% (n=14), and hypertension in 7% (n=1). The mean operating time was 64.6 minutes. The mean hospital stay was 2.2 days. After a mean follow up of 12.08 months, the radiological and symptomatic successes were 100% and 86.6%, respectively. Laparoscopic renal cyst decortication using conventional monopolar device represents an effective and safe treatment option in the management of renal cyst without any need for more expensive energy sources.

[Complications of laparoscopic urological procedures]

Laparoscopic urology has evolved considerably during last decade as well as number and spectrum of surgical related complications. Experiences reported by laparoscopic trained groups allow preventing, promptly recognizing, and safe and efficient management of the laparoscopic related complications. We present our complications in all patients undergoing urological laparoscopic procedures from November 1992 to June 2005. A literature search was conduced to evaluate complications of every laparoscopic procedure.