Laparoscopic Reconstructive Renal Surgery
Sara L. Best, MD, Edward D. Matsumoto, MD, Jeffrey A. Cadeddu, MD
Schuessler et al1 described the first laparoscopic pyeloplasty in 1993, and since then many centers have adopted this minimally invasive approach. The reconstructive technique used mirrors open pyeloplasty procedures including Anderson-Hynes (dismembered) and Fenger pyeloplasty.2 Laparoscopic pyeloplasty is a challenging procedure with a steep learning curve. The surgeon must be comfortable working in close proximity to the renal hilum and be proficient at intracorporeal suturing.
Overall, complication rates range from 4% to 20% (mean, 11.4%).1-8 A urine leak occurring after laparoscopic pyeloplasty may lead to urinoma formation, urinary ascites, and long-term strictures. These complications can be avoided by creating a watertight anastomosis with absorbable sutures. Suturing devices like the EndoStitch (US Surgical, Norwalk, CT) device are available to assist the surgeon in achieving this objective.
Reconstruction should always be done over a stent with an indwelling Foley catheter left in for at least 24 hours. Drains should also be placed close to, but not touching, the anastomotic site.
Vascular complications can also occur during a laparoscopic pyeloplasty. Injury to a crossing vessel could potentially lead to an ischemic lower pole kidney. Computed tomography (CT) angiography may help identify crossing vessels and prevent such injuries. Major renal vessels can also be injured during the procedure. Avoiding extensive dissection in the hilar region can reduce such an injury. However, in case of a major vessel bleed, the surgeon should not hesitate to convert to an open procedure to gain control and repair the injury.
Postoperatively, the drain outputs can be followed. If output is excessive, a fluid creatinine level can be analyzed to determine whether it is urine or peritoneal fluid. If it is urine, bladder drainage can be instituted, if not already in place, to reduce intravesical pressure transmission via the ureteric stent. The vast majority of leaks will resolve spontaneously. Follow-up imaging with ultrasound or CT scans may be necessary to rule out urine collections if the patient becomes symptomatic or febrile. Such clinically significant collections of urine will require percutaneous drainage. Patients can be followed clinically, and most clinicians will arrange an intravenous pyelogram (IVP) or a nuclear renography approximately 3 months after pyeloplasty to document renal function and resolution of the obstruction. Re-obstruction may occur in up to 5% of cases, and these will usually occur within the first year. When this occurs, the re-obstruction can often be managed with an endopyelotomy. Long-term failures are not common.5
Recently, robotic platforms have been harnessed to help mitigate some of the technical challenges of standard laparoscopic pyeloplasty, especially to help ease the intracorporeal suturing during the reconstruction. Reports suggest that the complication rate of robotic- assisted laparoscopic pyeloplasty is similar to that of conventional laparoscopy. Large robotic pyeloplasty series by Mufarrij et al (140 patients)9 and Gupta et al (85 patients)10 had complication rates of 10.0% and 9.4%, respectively. A recent metaanalysis of 8 comparative studies of robotic and traditional laparoscopic pyeloplasties by Braga et al11 showed a statistically similar complication rate.
LAPAROSCOPIC RENAL CYST DECORTICATION
Renal cysts are common in adults, and occasionally they can bleed and become symptomatic or infected. Autosomal dominant polycystic kidney disease is one of the major causes of end-stage renal disease, and patients in their fourth decade of life can present with pain, hypertension, hematuria, or infection.12 Symptomatic cysts are managed by percutaneous drainage with or without sclerotherapy as a first-line therapy. If this fails, other options include open and laparoscopic decortication.
Morgan and Rader13 first described a laparoscopic approach to cyst decortication. Many other groups have adopted laparoscopic cyst decortication as part of the armamentarium in the management of symptomatic renal cysts.14-18 Results are fairly durable, and studies have shown that approximately 60% of patients remain free of symptoms after 2 years.19,20
Reported laparoscopic cyst decortication series have been small and complication rates vary, ranging from 0% to 43% (mean, 9.2%).14,17-25 Postoperative hemorrhage is one of the more common complications. A high degree of suspicion is necessary to avoid missing this complication. Patients with hemorrhage may present with flank pain, signs of hypovolemia, or both of these. A hematocrit and radiologic imaging (ie, CT scan) should be performed to help identify the source of the pain. Avoiding the renal parenchyma during the excision of the cyst can minimize the risk of bleeding.26 Hemostatic cellulose, Surgicel (Ethicon, Inc., Somerville, NJ), fibrin glue, or all of these if necessary, may also be used to control parenchymal bleeding. An argon beam coagulator can also be used to secure hemostasis if need be.26 McNally et al24 described the use of the Harmonic scalpel (Ethicon Endo-Surgery, Inc., Cincinnati, OH) as a tool to control intraoperative bleeding from the cut edge of the cyst. Despite the use of such devices, delayed postoperative bleeds requiring transfusions have been reported. Delayed hemorrhage should be managed conservatively; however, refractory bleeding may require selective renal artery embolization.
A urine leak is another complication of laparoscopic decortication. A urine leak may occur when an unrecognized entry into the collecting system is present. This may occur when decorticating cysts close to the renal hilum. The possibility of this type of injury can be minimized by the use of laparoscopic ultrasound to guide the unroofing of larger, deeper cysts and perihilar cysts.23 Intraoperatively, injury to the collecting system can be identified by preoperatively inserting a retrograde ureteral catheter to instill methylene blue or by administering intravenous indigo carmine and hydration with diuretics at the completion of the laparoscopic procedure.22,26 If an injury to the collecting system is identified, it should be closed laparoscopically with an absorbable suture. It may also be prudent to leave a ureteral stent and a drain in the retroperitoneum after repair of a collecting system violation. Careful preoperative planning with a CT scan can also help the surgeon predetermine which large cysts to decorticate and localize those that are close to the hilum.
In general, laparoscopic decortication is a safe procedure with good results. Complications can be minimized by a careful preoperative workup as well as diligent hemostasis intraoperatively.
Nephroptosis has been recognized and treated with a variety of surgical techniques. The classic patient is a thin female who presents with renal colic, a painful abdominal mass associated with a positional change, or both of these. The mechanism is felt to be due to a ptotic kidney that kinks the ureter or obstructs the hilar blood flow. Patients are evaluated with an IVP performed with the patient in the supine and upright positions.
Documentation of renal descensus >2 vertebral bodies and evidence of obstruction with symptoms are acceptable indications to intervene surgically. Nuclear renal scans have also been used to demonstrate a decrease in the split renal function of the affected kidney with an upright positional change.26 Open nephropexy has been utilized in the past to fix the kidney in a more stable retroperitoneal position, with the goal of alleviating symptoms. Success rates average around 68.6%.27 Laparoscopic nephropexy was first reported by Urban et al28 in 1993 in a case report, which resulted in symptomatic relief. Since then, many other groups have reported laparoscopic nephropexy success rates ranging from 75% to 100%.26,29-33 However, it is important to note that the definition of “success” varies greatly in these reports, from no radiographic evidence of nephroptosis to symptom improvement to complete resolution of pain.
Complication rates for laparoscopic nephropexy range from 0% to 50% (mean, 9.5%).26,27,29-36 Several authors cited complications related to the carbon dioxide insufflant, including subcutaneous emphysema reported by Golab et al32 (4.8%) and Gözen et al30 (12.5%), as well as chemical peritonitis in 2/6 patients in a series by Matsui et al.36 One other potential complication of laparoscopic nephropexy is the risk of nerve entrapment while securing the kidney to the posterior abdominal wall. Fahlenkamp et al34 reported one case of iliohypogastric nerve entrapment during laparoscopic nephropexy.
Chueh et al35 reported ipsilateral thigh numbness in a patient who underwent retroperitoneoscopic nephropexy, which resolved by 9 months without intervention. Clearing the securing site on the retroperitoneal musculature of any obscuring fat will enable the surgeon to avoid such injuries. Fornara et al31 reported one patient with a postoperative urinary tract infection treated successfully with antibiotics and 2 patients with moderate retroperitoneal hematoma, both requiring no intervention.
Laparoscopic nephropexy can be performed safely by incorporating key maneuvers including adequate exposure of the posterior muscle wall to identify nerve and vascular structures and the use of an absorbable mesh or 3-stitch/point sutures to prevent torsion and decrease the likelihood of failure.
- Schuessler WW, Grune MT, Tecuanhuey LV, Preminger GM. Laparoscopic dismembered pyeloplasty. J Urol. 1993;150:1795-1799.
- Siqueira TM Jr, Nadu A, Kuo RL, Paterson RF, Lingeman JE, Shalhav AL. Laparoscopic treatment for ureteropelvic junction obstruction. Urology. 2002;60: 973- 978.
- Chen RN, Moore RG, Kavoussi LR. Laparoscopic pyeloplasty. Indications, technique, and long-term outcome. Urol Clin North Am. 1998;25:323-330.
- Eden CG, Cahill D, Allen JD. Laparoscopic dismembered pyeloplasty: 50 consecutive cases. BJU Int. 2001;88:526-531.
- Jarrett TW, Chan DY, Charambura TC, Fugita O, Kavoussi LR: Laparoscopic pyeloplasty: the first 100 cases. J Urol. 2002;167:1253-1256.
- Moore RG, Averch TD, Schulam PG, Adams JB, Chen RN, Kavoussi LR. Laparoscopic pyeloplasty: experience with the initial 30 cases. J Urol. 1997;157:459- 462.
- Pardalidis NP, Papatsoris AG, Kosmaoglou EV. Laparoscopic treatment of ureteropelvic junction obstruction. J Urol. 2002;168:1937-1940; discussion 1940.
- Soulié M, Salomon L, Patard JJ, et al. Extraperitoneal laparoscopic pyeloplasty: a multicenter study of 55 procedures. J Urol. 2001;166:48-50.
- Mufarrij PW, Woods M, Shah OD, et al. Robotic dismembered pyeloplasty: a 6-year, multi-institutional experience. J Urol. 2008;180:1391-1396. Epub 2008 Aug 15.
- Gupta NP, Nayyar R, Hemal AK, Mukherjee S, Kumar R, Dogra PN. Outcome analysis of robotic pyeloplasty: a large single-centre experience. BJU Int. 2009 Oct 28 [Epub ahead of print]
- Braga L, Pace K, DeMaria J, Lorenzo A. Systematic review and meta-analysis of robotic-assisted versus conventional laparoscopic pyeloplasty for patients with ureteropelvic junction obstruction: effect on operative time, length of hospital stay, postoperative complications, and success rate. Eur Urol. 2009 Apr 1 [Epub ahead of print]
- Gabow PA. Autosomal dominant polycystic kidney disease. N Engl J Med. 1993;329(5):332-42.
- Morgan C Jr, Rader D. Laparoscopic unroofing of a renal cyst. J Urol. 1992;148: 1835-1836.
- Chehval M, Neilsen C. Laparoscopic cyst decompression of polycystic kidney disease. J Endourol. 1995;9:281-282.
- Elzinga LW, Barry J, Bennett WM. Surgical management of painful polycystic kidneys. Am J Kidney Dis. 1993;22:532-537.
- Rubenstein SC, Hulbert JC, Pharand D, Schuessler WW, Vancaillie TG, Kavoussi LR. Laparoscopic ablation of symptomatic renal cysts. J Urol. 1993;150:1110-1101.
- Stoller ML, Irby PB 3rd, Osman M, Carroll PR. Laparoscopic marsupialization of a simple renal cyst. J Urol. 1993;150:1486-1488.
- Teichman JM, Hulbert J. Laparoscopic marsupialization of the painful polycystic kidney. J Urol. 1995;153:1105-1107.
- Brown JA, Torres VE, King BF, Segura JW: Laparoscopic marsupialization of symptomatic polycystic kidney disease. J Urol. 1996;156:22-27.
- Lifson BJ, Teichman JM, Hulbert JC. Role and long-term results of laparoscopic decortication in solitary cystic and autosomal dominant polycystic kidney disease. J Urol. 1998;159:702-706.
- Abbaszadeh S, Taheri S, Nourbala M.H. Laparoscopic decortication of symptomatic renal cysts: experience from a referral center in Iran. Int J Urol. 2008;15: 486-489. Epub 2008 Apr 14.
- Atug F, Burgess SV, Ruiz-Deya, G, Mendes-Torres F, Castle EP, Thomas R. Long- term durability of laparoscopic decortication of symptomatic renal cysts. Urology. 2006;68:272-275.
- Dunn MD, Portis AJ, Naughton C, Shalhav A, McDougall EM, Clayman RV. Laparoscopic cyst marsupialization in patients with autosomal dominant polycystic kidney disease. J Urol. 2001;165:1888-1892.
- McNally ML, Erturk E, Oleyourryk G, Schoeniger L. Laparoscopic cyst decortication using the harmonic scalpel for symptomatic autosomal dominant polycystic kidney disease. J Endourol. 2001;15:597-599.
- Shiraishi K, Eguchi S, Mohri J, Kamiryo Y. Laparoscopic decortication of symptomatic simple renal cysts: 10-year experience from one institution. BJU Int. 2006;98:405-408.
- McDougall EM, Afane JS, Dunn MD, Collyer WC, Clayman RV: Laparoscopic nephropexy: long-term follow-up—Washington University experience. J Endourol. 2000;14:247-250.
- Plas E, Daha K, Riedl CR, Hubner WA. Long-term followup after laparoscopic nephropexy for symptomatic nephroptosis. J Urol. 2001;166: 449-452.
- Urban DA, Clayman R, Kerbl K, Figenshau RS, McDougall EM. Laparoscopic nephropexy for symptomatic nephroptosis: initial case report. J Endourol. 1993;7:2730.
- Hübnera, WA, Schlarp O, Riedl C, Plas E, Reiter WJ. Laparoscopic nephropexy using tension-free vaginal tape for symptomatic nephroptosis. Urology. 2004;64:372-374.
- Gözen AS, Rassweiler JJ, Neuwinger F, et al. Long-term outcome of laparoscopic retroperitoneal nephropexy. J Endourol. 2008;22:2263-2267.
- Fornara P, Doehn C, Jocham D. Laparoscopic nephropexy: 3-year experience. J Urol. 1997;158:1679-1683.
- Golab A, Slojewski M, Gliniewicz B, Sikorski A. Retroperitoneoscopic nephropexy in the treatment of symptomatic nephroptosis with 2-point renal fixation. Surg Laparosc Endosc Percutan Tech. 2009;19:356-359.
- Wyler SF, Sulser T, Casella R, Hauri D, Bachmann A. Retroperitoneoscopic nephropexy for symptomatic nephroptosis using a modified three-point fixation technique. Urology. 2005;66:644-648.
- Fahlenkamp D, Rassweiler J, Fornara P, Frede T, Loening SA. Complications of laparoscopic procedures in urology: experience with 2,407 laparoscopic procedures in urology: experience at 4 German centers. J Urol. 1999;162:765-770; discussion 770-771.
- Chueh SC, Hsieh JT, Chen J, Young YL, Chen SC, Tu YP. Retroperitoneoscopic nephropexy for symptomatic nephroptosis. Surg Endosc. 2002;16:1603-1607. Epub 2002 May 3.
- Matsui Y, Matsuta Y, Okubo K, Yoshimura K, Terai A, Arai Y. Laparoscopic nephropexy: treatment outcome and quality of life. Int J Urol. 2004;11:1-6.