Laparoscopic nephrectomy for adult polycystic kidney disease: safety, feasibility, and early outcomes

Dialysis and Transplant Considerations in Autosomal Dominant Polycystic Kidney Disease

Autosomal dominant polycystic kidney disease (ADPKD) is the fourth leading cause of kidney replacement therapy. Unfortunately, the need for dialysis or kidney transplantation is a foreseeable outcome for many patients affected by ADPKD. We review some of the unique issues that should be considered in the management of patients with ADPKD who require dialysis or kidney transplantation. The choice of dialysis modality may be influenced by the enlarged kidneys and liver, but peritoneal dialysis should not be excluded as an option, as studies do not consistently show that there is an increased risk for technique failure or peritonitis. The optimal kidney replacement therapy option remains kidney transplantation; however, nephrectomy may be needed if there is insufficient space for the allograft. Living donor candidates from at-risk families need to be excluded from carrying the disease either by diagnostic imaging criteria or genetic testing. Other potential transplant issues, such as malignancy and cardiovascular and metabolic risks, should also be recognized. Despite these issues, patients with ADPKD requiring dialysis or kidney transplantation generally have more favorable outcomes as compared to those with other causes of chronic kidney disease. Further studies are still needed to personalize the therapeutic approach for those receiving kidney replacement therapy and eventually improve clinical outcomes.

Laparoscopic Nephrectomy for Massive Kidneys in Polycystic Kidney Disease

Background and Objectives:

Laparoscopic nephrectomy is now considered a feasible surgical approach, even for large kidneys. In the case of massive kidneys, laparoscopy can be problematic, so that some authors suggest an open approach. However, previous studies have shown that hand-assisted laparoscopic nephrectomy (HALN) may represent a useful compromise.

We describe our hand-assisted laparoscopic technique for nephrectomy of large kidneys (> 2500 g) to encourage the use of laparoscopy for nephrectomy in autosomal dominant polycystic kidney disease.

Methods:

We retrospectively analyzed data from 26 nephrectomies in 17 patients who underwent HALN for ADPKD and compared them to a group of 22 nephrectomies in 18 patients with open surgical technique.

Results:

The duration of the procedure was significantly longer in the laparoscopic group, with a median of 180 minutes versus 90 minutes for the unilateral nephrectomies, and 240 minutes versus 122 minutes for the bilateral procedures. The median kidney weight in the open group was 2500 g (range 1300 – 4500 g), while the median weight in the HALN group was 2375 g (range 1000 – 4700 g). The median hospital stay was comparable. No significant differences were recorded in the intra- and postoperative complication rate.

Conclusion:

Hand-assisted laparoscopic nephrectomy can be considered a technique of choice for patients suffering from ADPKD requiring nephrectomy, also with massive kidneys weighing more than 3500 g. Compared to open nephrectomy, HALN can be performed safely, with reasonably longer operating times and without major complications, and offers a significant reduction in hospitalization time, pain and postoperative discomfort.

Partial (two-thirds) nephrectomy in pigs: A comparison of three surgical approaches

Partial (2/3) nephrectomy can be performed via the laparoscopic, retroperitoneal, and transperitoneal approach. Outcomes of the three approaches were compared in this study. 2/3 nephrectomy were performed in 21 healthy Bama miniature pigs (mean bodyweight 20.59±2.78kg). Pigs were divided into three groups: those that underwent 2/3 nephrectomy via laparoscopy (LN group, n=7), the retroperitoneal approach (RN group, n=7), or the transperitoneal approach (TN group, n=7). We monitored pre- and postoperative physiologic parameters, blood cell count, and stress and renal function biomarkers. Differences among groups were analyzed. 2/3 nephrectomy was successfully performed in all pigs without any complications. Mean surgical time in the LN group (60.71±7.34min) and the TN group (58.57±4.72min) was significantly longer than that in the RN group (41.14±5.33min). Warm ischemia in the LN group (38±7.57min) was significantly longer than that in the TN group (28.86±4.53min), which was significantly longer than that in the RN group (17.86±2.34min). The postoperative serum concentration of C-reactive protein in the TN group was significantly higher than that in the LN group (p<0.05). So retroperitoneal approach was best choice in case of bilateral renal lesion resulted in shortest ischemia time, and laparoscopic partial nephrectomy should be the primary choice in majority situations resulted in less body stress, smaller surgical incisions and less blood loss.

[Polycystic kidney disease and kidney transplantation]

OBJECTIVES

To perform a state of the art about autosomal dominant polykystic kidney disease (ADPKD), management of its urological complications and end stage renal disease treatment modalities.

MATERIAL AND METHODS

An exhaustive systematic review of the scientific literature was performed in the Medline database (http://www.ncbi.nlm.nih.gov) and Embase (http://www.embase.com) using different associations of the following keywords (MESH): "autosomal dominant polykystic kidney disease", "complications", "native nephrectomy", "kidney transplantation". Publications obtained were selected based on methodology, language, date of publication (last 10 years) and relevance. Prospective and retrospective studies, in English or French, review articles; meta-analysis and guidelines were selected and analyzed. This search found 3779 articles. After reading titles and abstracts, 52 were included in the text, based on their relevance.

RESULTS

ADPKD is the most inherited renal disease, leading to end stage renal disease requiring dialysis or renal transplantation in about 50% of the patients. Many urological complications (gross hematuria, cysts infection, renal pain, lithiasis) of ADPKD required urological management. The pretransplant evaluation will ask the challenging question of native nephrectomy only in case of recurrent kidney complications or large kidney not allowing graft implantation. The optimum timing for native nephrectomy will depend on many factors (dialysis or preemptive transplantation, complication severity, anuria, easy access to transplantation, potential living donor).

CONCLUSION

Pretransplant management of ADPKD is challenging. A conservative strategy should be promoted to avoid anuria (and its metabolic complications) and to preserve a functioning low urinary tract and quality of life. When native nephrectomy should be performed, surgery remains the gold standard but renal arterial embolization may be a safe option due to its low morbidity.

Suitability of Patients with Autosomal Dominant Polycystic Kidney Disease for Renal Transcatheter Arterial Embolization

In patients with autosomal dominant polycystic kidney disease (ADPKD), massive renal enlargement is a serious problem. Renal transcatheter arterial embolization (TAE) can reduce renal volume (RV), but effectiveness varies widely, and the reasons remain unclear. We investigated factors affecting renal volume reduction rate (RVRR) after renal TAE in all 449 patients with ADPKD who received renal TAE at Toranomon Hospital from January of 2006 to July of 2013, including 228 men and 221 women (mean age =57.0±9.1 years old). One year after renal TAE, the RVRR ranged from 3.9% to 84.8%, and the least squares mean RVRR calculated using a linear mixed model was 45.5% (95% confidence interval [95% CI], 44.2% to 46.8%). Multivariate analysis using the linear mixed model revealed that RVRR was affected by the presence of large cysts with wall thickening (regression coefficient [RC], -6.10; 95% CI, -9.04 to -3.16; P<0.001), age (RC, -0.82; 95% CI, -1.03 to -0.60; P<0.001), dialysis duration (RC, -0.10; 95% CI, -0.18 to -0.03; P<0.01), systolic BP (RC, 0.39; 95% CI, 0.19 to 0.59; P<0.001), and the number of microcoils used for renal TAE (RC, 1.35; 95% CI, 0.83 to 1.86; P<0.001). Significantly more microcoils were needed to achieve renal TAE in patients with younger age and shorter dialysis duration. In conclusion, cyst wall thickening had an important effect on cyst volume reduction. Renal TAE was more effective in patients who were younger, had shorter dialysis duration, or had hypertension, parameters that might associate with cyst wall stiffness and renal artery blood flow.

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.