Simple nephrectomy: managing the difficult case: xanthogranulomatous pyelonephritis and autosomal dominant polycystic kidney disease

Comparison of laparoscopic and hand-assisted laparoscopic nephrectomy for inflammatory renal disease: which is the preferred approach?

Aims:

Management of inflammatory renal disease (IRD) can still be technically challenging for laparoscopic procedures. The aim of the present study was to compare the safety and feasibility of laparoscopic and hand-assisted laparoscopic nephrectomy in patients with IRD.

Patients and methods:

We retrospectively analyzed the data of 107 patients who underwent laparoscopic nephrectomy (LN) and hand-assisted laparoscopic nephrectomy (HALN) for IRD from January 2008 to March 2020, including pyonephrosis, renal tuberculosis, hydronephrosis, and xanthogranulomatous pyelonephritis. Patient demographics, operative outcomes, and postoperative recovery and complications were compared between the LN and HALN groups. Multivariable logistic regression analysis was conducted to identify the independent predictors of adverse outcomes.

Results:

Fifty-five subjects in the LN group and 52 subjects in the HALN group were enrolled in this study. In the LN group, laparoscopic nephrectomy was successfully performed in 50 patients (90.9%), while four (7.3%) patients were converted to HALN and one (1.8%) case was converted to open procedure. In HALN group, operations were completed in 51 (98.1%) patients and conversion to open surgery was necessary in one patient (1.9%). The LN group had a shorter median incision length (5 cm versus 7 cm, p < 0.01) but a longer median operative duration (140 min versus 105 min, p < 0.01) than the HALN group. There was no significant difference in blood loss, intraoperative complication rate, postoperative complication rate, recovery of bowel function, and hospital stay between the two groups. Multivariable logistic regression revealed that severe perinephric adhesions was an independent predictor of adverse outcomes.

Conclusion:

Both LN and HALN appear to be safe and feasible for IRD. As a still minimally invasive approach, HALN provided an alternative to IRD or when conversion was needed in LN.

Simple Nephrectomy in a Tertiary Care Safety Net Hospital-Patient Characteristics, Causes, Cost, and Renal Function Implications

OBJECTIVE

To evaluate factors associated with simple nephrectomy at a safety net hospital with a diverse patient population and large catchment area. Simple nephrectomy is an underreported surgery. Performance of simple nephrectomy may represent a failure of management of underlying causes.

METHODS

We performed a retrospective review of simple nephrectomies performed at a major urban safety net hospital from 2014 to 2019. Detailed demographic, surgical, and renal functional outcomes were abstracted. We assessed the medical and social factors leading to performance of simple nephrectomy and report contemporaneous perception of preventability of the simple nephrectomy by the surgeon.

RESULTS

Eighty-five patients underwent simple nephrectomy during the study period; 55% were non-white, 77% were women, and the median age at time of surgery was 46 years. The most common medical factors contributing to simple nephrectomy were stone disease in 55.3%, followed by retained ureteral stent (30.6%) and stricture (30.6%). The most common social factors were lack of insurance (58.5%), substance abuse issues (32.3%), mental health issues (24.6%), and immigration status (18.5%). In 38.8% of cases, the provider felt the surgery was preventable if medical factors leading to simple nephrectomy were properly addressed.

CONCLUSIONS

Simple nephrectomy is a common surgery in the safety net hospital setting. Both medical and sociologic factors can lead to simple nephrectomy, and awareness of these factors can lead efforts to mitigate them. This review has led to the implementation of strategies to minimize occurrences of retained stents in our patients.

Laparoscopic nephrectomy in xanthogranulomatous pyelonephritis

Introduction

The aim of this article was to report our experience with laparoscopic and retroperitoneoscopic nephrectomy in patients with xanthogranulomatous (XPG) pyelonephritis.

Material and methods

Between November 2002 and September 2010, 27 patients, with a mean age of 61.1 years (range 43–85), underwent laparoscopic nephrectomy for a unilateral nonfunctioning kidney, because of xanthogranulomatous pyelonephritis. Patient's data was collected retrospectively and included patient age, gender, intraoperative conversion rate, operative time, estimated blood loss, length of hospital stay, perioperative transfusion rate, renal function pre- and postoperatively and postoperative complications.

Results

Laparoscopic nephrectomy was successful in 26 patients. It was transperitoneal in 15 patients, retroperitoneal in 11 patients and in one patient the operation was initiated as retroperitoneal and converted to transperitoneal. One conversion to open surgery was needed. The mean operative time was 193.6 minutes (range 123–340). The mean estimated blood loss was 223.5 ml (range 30–1000). The mean hospital stay was 4.8 days (range 3–12). The transfusion rate was 29.6%. Serum creatinine was 1.3 mg/dl the day before and the day after the operation. Major complications occurred in patients (11.1%).

Conclusions

Laparoscopic nephrectomy should be considered as an initial approach for XGP. The indications for laparoscopic nephrectomy should be extended to these patients.

Post transplant urinary tract infection in Autosomal dominant polycystic kidney disease a perpetual diagnostic dilema - 18-fluorodeoxyglucose - Positron emission computerized tomography - A valuable tool

Urinary tract infection (UTI) is the most common infection contracted by renal allograft recipients. In patients of autosomal dominant polycystic kidney disease (ADPKD), cyst infection presents a complex diagnostic and therapeutic challenge especially in the post transplant period. Accurate diagnosis forms the cornerstone in salvaging the graft from potentially catastrophic outcome. We describe a case of xanthogranulomatous pyelonephritis (XPN) in the native kidney in a patient of post transplant ADPKD which presented as frequently relapsing UTI with graft dysfunction where in accurate diagnosis was made possible with the aid of 18-fluorodeoxyglucose (FDG) - Positron emission computerized tomography (PET/CT).

Laparoscopic versus open radical nephrectomy for xanthogranulomatous pyelonephritis: Contemporary outcomes analysis

BACKGROUND AND PURPOSE

Early experience with laparoscopic nephrectomy for xanthogranulomatous pyelonephritis (XGP) was associated with high conversion and complication rates. We describe our institution's experience with this procedure compared with a contemporary cohort of patients with XGP treated by open nephrectomy.

PATIENTS AND METHODS

Retrospective review of surgical pathology reports from radical nephrectomies at our institution between 1995 and 2005 yielded a diagnosis of XGP in 12 patients, 6 of whom had undergone laparoscopic surgery. Each patient's medical records were reviewed, with intraoperative and postoperative parameters, including complications, being recorded.

RESULTS

Transperitoneal laparoscopic nephrectomy was successful in five patients (83%). Hand-assist ports were utilized in two patients because of failure to progress. The operative times were 301 +/- 106 minutes and 167 +/- 40 minutes in the laparoscopic and open-surgery groups, respectively (P = 0.03). There was no statistical difference with regard to estimated blood loss, transfusion rate, or parenteral analgesic requirements, but there was a trend toward a shorter stay for the laparoscopic group. Complications were noted in three and two patients in the laparoscopic and open-surgery groups, respectively.

CONCLUSIONS

The outcomes of nephrectomy for XGP were similar regardless of surgical approach. The results in patients with XGP were similar to initial reports in the literature and may be dependent on surgeon experience. We believe that in experienced hands, laparoscopic nephrectomy may be offered to patients with XGP.

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 Laparoscopic Approach to Simple Nephrectomy

Laparoscopic nephrectomy is commonly employed today for both malignant and benign renal conditions, yet the learning curve for all but the simplest procedures remains quite steep. Hand-assisted laparoscopic nephrectomy (HALN) bridges the gap between standard laparoscopy and open surgery, allowing urologists to develop laparoscopic skills while offering the advantages of minimally invasive surgery. Simple laparoscopic nephrectomy, performed for benign disorders, can at times prove to be challenging because of inflammation around the renal hilum. Meticulous dissection during HALN utilizing the intra-abdominal hand for tactile feedback, retraction, and blunt dissection may improve one's capabilities compared with the standard laparoscopic approach.

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.