Transperitoneal Laparoscopic Nephrectomy for Autosomal Dominant Polycystic Kidney Disease

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tapraid2/jls-jsls/jls-jsls/jls00312/jls2895d12z xppws Sⴝ1 10/30/12 19:00 Art: 12-01-005

SCIENTIFIC PAPER

Transperitoneal Laparoscopic Nephrectomy for Autosomal Dominant Polycystic Kidney Disease Gre´gory Verhoest, MD, Arnaud Delreux, MD, Romain Mathieu, MD, Jean-Jacques Patard, MD, Ce´cile Vigneau, MD, Nathalie Rioux-Leclercq, MD, Karim Bensalah, MD ABSTRACT Objective: This study focuses on laparoscopic nephrectomy for autosomal dominant polycystic kidney disease (ADPKD). Material and Methods: We retrospectively reviewed 21 consecutive patients who had previously undergone laparoscopy between 2007 and 2010. Data were compared to that obtained from 19 consecutive patients who had open surgery between 2004 and 2007. Clinical parameters, operative data, perioperative mortality, postoperative complications, and length of hospital stay were compared using ␹2 (␹2) and Student t tests for qualitative and quantitative variables, respectively. Results: Nephrectomy is usually performed to create space for renal transplantation (81% and 79%, respectively). Operating time was longer with the laparoscopic approach (180 min vs. 128 min, P ⫽ .001). Blood loss was comparable in the 2 groups (154 vs. 222 ml, P ⫽ .359) but 3 patients were transfused in the open surgery group as compared with 1 patient in the laparoscopic group. No conversion was needed. There was a trend in the laparoscopic group with respect to lower consumption of analgesics in the postoperative period (P ⫽ .06). Delay to transit recovery (2.1 d vs 4.1 d, P ⬍ .001) and hospital stay (5.2 d vs. 8.28 d, P ⫽ .002) were significantly decreased in the laparoscopic group. The interval from surgery to renal transplantation was lower in patients operated on laparoscopically (3.1 vs. 12 mo). Complications occurred in 33% of the patients in the laparoscopic group as compared with 68% in the open surgery group (P ⫽ .22). Severe complications were less frequent in the laparoscopic group (9.5% vs. 37%, P ⫽ .04).

Rennes University Hospital, France (Department of Urology: Drs Verhoest, Delreux, Mathieu, Patard, Bensalah; Department of Nephrology: Dr Vigneau; Department of Pathology: Dr Rioux-Leclercq). Address correspondence to: Gre´gory Verhoest, MD, Department of Urology, Rennes University Hospital, Henri Le Guillou St, 35033 Rennes Cedex, France, Telephone: ⫹332 99284270, Fax: ⫹332 99284113, E-mail: [email protected]_rennes.fr DOI: 10.4293/108680812X13462882736178 © 2012 by JSLS, Journal of the Society of Laparoendoscopic Surgeons. Published by the Society of Laparoendoscopic Surgeons, Inc.

Conclusion: Laparoscopic nephrectomy is a feasible and safe procedure for ADPKD. Morbidity is significantly reduced compared with the open approach. Key Words: Kidney, Renal insufficiency, Polycystic kidney, Laparoscopy.

INTRODUCTION Autosomal dominant polycystic kidney disease (ADPKD) is a common hereditary disorder, with a prevalence of 1/1000. Progressive renal disease occurs in 45% of the patients by the age of 60, and 10% of renal transplant patients are individuals affected by ADPKD.1 ADPKD originates from a mutation in either the ADPKD-1 or ADPKD-2 gene, altering the synthesis of polycystin-1 and 2, respectively. Loss of function of these proteins causes the clinical syndrome characterized by the progressive compression and destruction of the renal parenchyma by multiple enlarging cysts.2 Massive enlarged polycystic kidneys can become symptomatic and require nephrectomy. Furthermore, surgery may also be needed before renal transplantation, when polycystic kidneys are too large to safely implant a renal transplant in the iliac fossa. Because of the volume of ADPKD kidneys, the open surgery approach has traditionally been used. However, due to the advantages of laparoscopic nephrectomy in terms of reduced hospital stay, postoperative pain, and speed of recovery, laparoscopy for ADPKD kidneys has been reported by some centers. Despite its advantages, this technique is still uncommon.3–10 The objective of this study is to describe a technique of laparoscopic ADPKD nephrectomy and compare its surgical outcomes to those of the open approach.

MATERIALS AND METHODS Patient Demographics Between December 2007 and February 2010, 21 consecutive nonselected patients with polycystic kidneys underwent laparoscopic nephrectomy. None of the patients

JSLS (2012)16:000 – 000

1

tapraid2/jls-jsls/jls-jsls/jls00312/jls2895d12z xppws Sⴝ1 10/30/12 19:00 Art: 12-01-005 Transperitoneal Laparoscopic Nephrectomy for Autosomal Dominant Polycystic Kidney Disease, Verhoest G et al.

underwent open surgery during this time period. All surgeries were performed by the same surgeon (KB). These patients were compared to a group of 19 patients who had consecutively received open surgery between January 2004 and December 2007, by one surgeon (JJP). The following variables were analyzed: age, sex, ASA score, body mass index (BMI), maximum size of the kidney on the CT scan, indication, operative time, blood loss, cumulative dose of morphine sulphate, time to transit recovery, hospital stay, blood transfusion, postoperative complications, and delay between nephrectomy and renal transplantation. Complications were graded according to Clavien’s modified classification.11 Surgical Technique Each patient received a CT scan preoperatively to evaluate kidney volume and exclude potential renal tumors. Patients were placed on a low-residue diet 3 d before surgery. A urethral catheter was systematically placed. No antibioprophylaxis was administered. Laparoscopic Technique F1

The patient was placed in a 3⁄4 lateral decubitus position and secured with adhesive tapes (Figure 1). The table was not flexed and could be rotated in case of conversion. A mini-laparotomy was made at the umbilicus, and a 12-mm optical port was inserted. We used a 10-mm, 30degree laparoscope in all cases. Under visual control, 3 operating trocars were placed: a 5-mm trocar under the subcostal margin on the midclavicular line, a 12-mm in the iliac fossa, and a 5-mm just inferior to the xiphoid to

Figure 2. Position of the different ports for a right nephrectomy, and the abdominal incision.

retract the liver in case of nephrectomy on the right side (Figure 2). The first step was the mobilization of the right colon to expose the anterior surface of the kidney. Attention was paid when mobilizing the duodenum, because of potential adhesions due to cyst infection. Dissection of the vena cava was not performed. At the lower pole of the kidney, the gonadal vein was shifted downward. Gerota’s fascia was then incised to find the plane between the psoas muscle and the kidney. At this time, an additional 5-mm trocar was inserted in the flank to lift the kidney and expose the renal hilum. The ureter was identified and sectioned between two 5-mm Hem-o-lok clips. The renal pedicle was progressively dissected until the renal vein was exposed. The renal artery could be viewed behind the vein in all cases. The artery was secured with 10-mm Hem-o-lok clips and cut. The renal vein was sectioned between three 12-mm Hem-o-lok clips. The kidney was completely mobilized in the simple nephrectomy plan. The adrenal gland was spared in all cases. The kidney was removed using a 7-cm Pfannenstiel incision. No retrieval bag was used for the extraction due to the increased size of the polycystic kidneys. If an en bloc extraction could not be made, the specimen was cut into several pieces through the incision. Open Technique

Figure 1. Installation of the patient on the operative table for a right nephrectomy.

2

A transperitoneal technique was used in all cases. A subcostal incision was performed from the midline to the flank. After reflection of the colon, the renal pedicle was dissected and sectioned. The kidney was mobilized in a

JSLS (2012)16:000 – 000

F2

tapraid2/jls-jsls/jls-jsls/jls00312/jls2895d12z xppws Sⴝ1 10/30/12 19:00 Art: 12-01-005

2 groups (154mL vs. 222mL, P ⫽ .359), but more patients received blood transfusions in the open group (1 vs. 3 patients in the open group). Operating time was longer with the laparoscopic approach (180 min vs. 128 min, P ⫽ .001). Lower amounts of analgesics were administered in the laparoscopic group, although the differences were not significant (17 vs. 27 mg, P ⫽ .06). Time to transit recovery (2.1 vs. 4.1 d, P ⬍ .001) and duration of hospital stay were significantly shorter in the laparoscopic group (5.2 vs. 8.28 d, P ⫽ .002). No conversion to open surgery was needed in the laparoscopic group. The specimen had to be morcellated in 12 cases. No malignant tumors were found upon pathological analysis in both groups. A lower number of complications was found in the laparoscopic group, but the overall difference was not significant (33% vs 68%, P ⫽ .12). Severe complications (grade ⱖ3 according to Clavien classification) were significantly more frequent in the open nephrectomy group (9.5% in the laparoscopic group vs 37% in the open group, P ⫽ .04). Details of complications are reported in Table 3. Postsurgical complications (2 wound dehiscences) only occurred

simple nephrectomy plan and removed, sparing the adrenal gland. Data Analysis Qualitative and quantitative variables were compared using ␹2 and Student t tests, respectively. All analyses were conducted with the statistical package for the Social Sciences version 17.0 (SPSS Inc, Chicago, IL, USA), and P value significance was set at 0.05.

RESULTS

T1

T2

Twenty-one patients were enrolled in the laparoscopic group and 19 in the open group. They were comparable in terms of age, sex, body mass index (BMI), kidney maximum diameter, and ASA score (Table 1). Seventeen laparoscopic (81%) and 15 open surgery patients (79%) underwent nephrectomy to allow sufficient space prior to transplantation. Characteristics of the patients are depicted in Table 1. In terms of surgical parameters (Table 2), there was no difference regarding estimated blood loss between the

Table 1. General Characteristics of the Population Studied Variables

Laparoscopy

Open

(nⴝ21)

(nⴝ19)

Women

13

9

Men

8

10

Mean age (years)

53 [41–71]

53 [40–71]

-

Mean BMI

25 [16–34]

23 [18–27]

.120

Mean largest size of the kidney on CT scan (cm)

23.5 [17–30]

26.8 [15–48]

.13

2

3

1

3

18

18

Dialysis

16

16

.787

Preliminary transplantation

2

3

-

Arterio-veinous dialysis fistula (AVF)

18

17

.72

Before transplantation

17

15

Symptomatic patient

4

3

Flank pain

4

1

Intracystic hemorrhage

1

0

Intestinal disorders

3

0

Urinary lithiasis

0

2

Sex:

P

.218

ASA score

.342

Surgical indication:

JSLS (2012)16:000 – 000

3

T3

tapraid2/jls-jsls/jls-jsls/jls00312/jls2895d12z xppws Sⴝ1 10/30/12 19:00 Art: 12-01-005 Transperitoneal Laparoscopic Nephrectomy for Autosomal Dominant Polycystic Kidney Disease, Verhoest G et al.

Table 2. Operative and Perioperative Parameters Variables

Laparoscopy

Open

(nⴝ21)

(nⴝ19)

P

Mean operative time (min)

180 [90–310]

128 [100–170]

.001

Estimated blood loss (mL)

154 [0–700]

222 [10–500]

.359

Mean cumulative dose of morphine sulphate use (mg)

17 [0–56]

27 [0–60]

.068

Mean hospital stay (days)

5.2 [3–11]

8.28 [5–24]

.002

Delay between nephrectomy and renal transplantation (months)

3.1

12

Mean time to transit recovery (days)

2.1 [1–3]

4.1 [2–10]

Post-operative transfusion

1

3

Surgical conversion

0

-

Table 3. Postoperative Complications According to Clavien Classification11 Variables

Laparoscopy Open

P

(nⴝ21)

(nⴝ19)

Complications:

7 (33.3%)

13 (68.4%)

Blood transfusion

1

3

Bowel injury

1

0

Adrenal injury

0

1

AVF thrombosis

2

3

Retroperitoneal hematoma

1

0 .12

Urinary tract infection

1

1

Diarrhea

1

0

Prolonged ileus

0

1

Digestive hemorrhage

0

1

Ischemic cerebrovascular accident

0

1

Wound dehiscence

0

2

Clavien 1–2

5/21 (23.8%)

6/19 (31.6%)

.6

Clavien 3–4

2/21 (9.5%)

7/19 (37%)

.04

in the open group with a mean follow-up of 12 mo. The time interval between nephrectomy and renal transplantation was shorter in the laparoscopic group (3.1 vs. 12 mo).

DISCUSSION Indications for ADPKD nephrectomy are intolerable pain, adjacent organ compression, or the need to create space 4

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