Publications

Laparoscopic nephrectomy for autosomal dominant polycystic kidneys in patients with end-stage renal disease on maintenance hemodialysis: 10-year single surgeon experience from an Indian center

Abstract

• Context :

  Pure laparoscopic nephrectomy in patients with ADPKD (autosomal dominant polycystic kidney disease) and ESRD (end-stage renal disease) on MHD (maintenance hemodialysis) is challenging with high incidence of complications. Limited experiences from India has been reported in these scenarios.

• Aims:

  To present a 10-year single surgeon experience from India in laparoscopic nephrectomy in autosomal dominant polycystic kidneys (ADPKD) and end-stage renal disease (ESRD) on maintenance hemodialysis (MHD). Settings and Design: Retrospective. Materials and Methods: Retrospective analysis of records of similar subset of patients who were offered laparoscopic nephrectomy between 2003 and 2012. Preoperative, operative and postoperative parameters were recorded. Few technical modifications were adopted over the years. Patients were sub-classified into two groups (Group I: 2003-2006, Group II: 2007-2012) based on surgical technique. Statistical Analysis Used: SAS software 9.1 version. Results: 75 patients (84 renal units, Group I: 31, Group II: 53) were included in this analysis. Unilateral procedure was performed in 66 and bilateral staged or simultaneous procedure in 9. Despite larger kidneys in Group II (mean longitudinal renal length 25.7 ± 3.4 vs 17.5 ± 2.7 centimeters, P <0.001), improved operative and postoperative profile were noted in Group II in several parameters-mean total operative time (205 ± 11.5 vs 310 ± 15.3 min, P = 0.00), time for specimen retrieval (30.5 ± 3.5 vs 45 ± 4.1 min, P = 0.02), postprocedure drop in hemoglobin (1.1 ± 0.1 vs 2.27 ± 0.03 grams/deciliter, P = 0.00). Conversion rates, intraoperative and postoperative events were also considerably less in Group II. Conclusions: Despite existence of comorbidities and technical difficulties, laparoscopic nephrectomy in patients with ADPKD with ESRD and on MHD is a feasible option. Technical modifications with increasing surgeon’s experience allows successful conductance of this approach in more complex cases with better outcome.

• Keywords :

  Laparoscopy, nephrectomy, polycystic kidney

Introduction

• Autosomal dominant polycystic kidney disease (ADPKD) is a hereditary disorder, which usually manifest during third and fourth decade of life with varied symptomatology notably abdominal pain, urinary tract infection, hematuria, hypertension. [1],[2],[3] A large number of patients with ADPKD ultimately present with end-stage renal disease [ESRD] requiring renal replacement therapy. [4] Nephrectomy is often mandated in patients with ADPKD and ESRD. Recurrent infection, pain, hematuria non-respondent to conservative measures and large kidney that interferes with satisfactory graft placement remain the most common reasons. Additionally, patients with ADPKD who do not undergo pretransplant native nephrectomy are more likely to suffer immunosuppressant-related complications, and need for posttransplant native nephrectomy has been reported in more than 40% of these subjects. [5]Open nephrectomy for ADPKD in patients with ESRD is fraught with increased morbidity and mortality. [3],[4] Laparoscopic nephrectomy for ADPKD was first reported by Clayman and associates in 1996. [2] Although it offers superior morbidity profile, the procedure is technically challenging with high incidence of complications. Several operators therefore prefer hand-assisted laparoscopic approach as a safer alternative in such scenarios. [6],[7],[8],[9] Till date only one citation is available from India narrating experience in pure laparoscopic extirpation of ADPKD in ESRD patients on MHD, albeit in smaller cohort of patients. [10] We narrate our 10-year experience in pure laparoscopic nephrectomy in ADPKD and discuss the difference in outcome obtained with the technical modifications we adopted over years.

Materials and methods

• Our database of patients undergoing laparoscopic nephrectomy for ADPKD and ESRD on MHD between 2003 and 2012 were retrospectively evaluated. Permission was obtained by the institutional review board.Preoperative Evaluation
• Patients were evaluated in detail including clinical and biochemical profile. Longitudinal renal dimension was derived from USG and NCCT scan parameters.
• Patient Selection

  All patients in this cohort were suffering from ADPKD and ESRD on MHD and undergoing workup for renal transplantation. Nephrectomy was advised prior to engraftment. In a patient planned for right iliac fossa allograft placement with bilaterally enlarged kidneys, our plan was to extirpate left renal unit 4-5 weeks prior to planned transplant followed by right nephrectomy during transplantation by cranial extension of the Gibson’s incision used for engraftment. In cases with a longer interval till renal transplantation, bilateral pretransplant nephrectomy was undertaken. Between 2003 and 2006, patients with a longitudinal kidney size <20 cm were chosen for laparoscopic approach and an open approach was offered in larger kidneys. If bilateral extirpations were mandated, they were performed in a staged manner.

  From 2007, all patients were offered laparoscopic approach irrespective of renal dimensions. In patients planned for bilateral pretransplant extirpations, simultaneous bilateral procedures were undertaken if preoperative longitudinal renal dimensions were <20 cm and patient parameters were acceptable following unilateral procedure.

• Preoperative Preparation

  All patients underwent a heparin-free hemodialysis on the evening prior to the operative day.

• Operative Exercise

  Patients were positioned in lateral decubitus with protection of pressure points. Parenteral antibiotic (third-generation cephalosporin) at adjusted doses (in accordance with creatinine clearance) was administered at induction. In all patients, a central venous line and an arterial line was inserted and close monitoring was conducted. All procedures were conducted under general anesthesia. All procedures were conducted through transperitoneal route.

• Operative Technique (2003-2006)

  A four port technique was adopted. First port (10 mm) was placed pararectal approximately two fingerbreadths cranial and two fingerbreadths lateral to umbilicus. Initial access was obtained by open technique (Hasson trocar). Another 10 mm port was inserted to the right of the first port at a point approximately midway between umbilicus and ipsilateral anterior superior iliac spine. Two additional ports (one 5 mm port left to the initial port and another 5 mm port in the ipsilateral flank was also inserted). After colonic reflection, entry was gained into the Gerotas fascia plane and renal mobilization was conducted along this plane. Harmonic scalpel (Ethicon Endosurgery, Johnson and Johnson) and hook electrocautery was used variably to facilitate dissection and control oozing. A large number of cysts of varying sizes and contents are usually encountered in these cases that completely distort the renal anatomy. Cysts hindering dissection and approach to real hilum were punctured using hook electrocautery. The cyst contents were immediately aspirated by introducing laparoscopic suction. Repeated similar sequence of steps were undertaken deflating the innumerable obstructing cysts. Thereafter renal hilum was entered, the renal artery was delineated and secured control. A thorough search was made for additional arteries which often coexist in these cases. After secured arterial control, attention was focused to control over renal vein. Depending on arterial caliber, titanium metal clips or hem-o-loc clips were used for arterial occlusion whereas in all cases vein was occluded using 10 mm hem-o-loc clips. No vascular stapler was employed in any case. After hilar control, ureter was secured control. Upper pole and posterior dissection was then completed followed by nephrectomy completion. Hemostasis was ensured and thorough intraperitoneal toileting was conducted using copious antibiotic mixed irrigant. Nephrectomy specimen was extracted by extension of right hand working port. A wide bore drain was inserted in all cases. Port and retrieval site closures were then undertaken.

• Operative Technique (2007-2012)

  Initial port positions were similar. However in large kidneys, additional ports (1 or 2 additional working ports) were utilized to facilitate dissection. A special multifunctional laparoscopic hook suction irrigation equipment (Ethicon Endopath Probe Plus II, Ethicon Endosurgery, Johnson and Johnson) that allows simultaneous hook electrocautery and suction-irrigation was used. Cysts hindering satisfactory dissection were deflated by puncturing with the hook electrocautery followed by immediate suction of the cyst contents with the same instrument. Identification and division of the ureterogonadal pedicle was performed first. The divided ureter was used as a fulcrum and dissection was continued cranially to gain entry to the renal hilum. Vascular control was achieved. After nephrectomy completion, a morcellator (Gynecare, Ethicon, Johnson and Johnson) was introduced by converting the 10 mm right hand working port (towards iliac fossa) to 12 mm port [Figure 1]a. Nephrectomy specimen was held by a forceps and morcellated taking care to avoid iatrogenic complications [Figure 1]b. Thorough peritoneal toileting was conducted following morcellation. Drain placement, port closures were undertaken [Figure 1]c

• Operative Parameters

  Operative parameters recorded were total operation duration, time to specimen retrieval, intraoperative complications, need for conversion to open technique.

• Postoperative Assessment

  Patients were closely monitored in intensive care unit with nephrology back-up. Heparin-free hemodialysis was repeated postprocedure. Blood transfusion was undertaken if post-procedure hemoglobin was <9 g/deciliter. Postoperative pain was assessed using numeric rating scale. Drain removal was undertaken once the drain output was <50 mL/day.

• Postoperative Parameters

  Postoperative parameters recorded were time to start orals, pain score, analgesic need, drop in hemoglobin, time to drain removal, need for blood transfusion, wound morbidity or other postoperative adverse events and total duration of in-hospital stay.

• Outcome Assessment/Statistical Analysis

  Patients were categorized into Group I (procedures between 2003 and 2006) and Group II (procedures between 2007 and 2012). Statistical analysis was performed using SAS software 9.1 version

Results

• Total 75 patients with ADPKD and ESRD (84 renal units) underwent laparoscopic nephrectomy. Fifty four were males and 21 were females. Thirty one procedures (29 unilateral and 1 staged bilateral) were performed between 2003 and -2006. Fifty three procedures were conducted after 2007. Of these 35 were unilateral, 3 were staged bilateral and 5 were simultaneous bilateral. The demographic parameters are depicted in [Table 1]. There was a significant difference in the mean longitudinal renal dimension between the 2 groups. [Table 2] projects the comparison of operative and postoperative profile of 2 groups. Despite larger kidneys in Group II, statistically significant improvement was perceived in the procedural performance duration, time to specimen retrieval and postoperative drop in hemoglobin. In Group I, 4 patients required conversion to open technique due to nonprogression during laparoscopy. In Group II, all procedures could be satisfactorily completed by laparoscopic approach. Iatrogenic events were also notably more in Group I (n = 4, colonic injury that was sutured intracorporeally – 2, splenic laceration – 2) than Group II (n = 1, splenic laceration – 1). In postoperative period, eight patients in Group I and two patients in Group II required blood transfusion. Two patients in Group I experienced paralytic ileus in the postoperative period that responded to conservative management. One patient in Group I experienced subacute intestinal obstruction postprocedure that mandated a laparoscopic exploration and adhesiolysis. Two patients in Group I experienced wound infection (retrieval site). No wound related adversities were remarked in Group II. On pathological analysis all specimens conferred to benign etiology.

Discussion

• Laparoscopic approach is currently considered a standard of care option for renal extirpation in both neoplastic and non-neoplastic kidneys. However in comparison to laparoscopic nephrectomy in other scenarios, performance of laparoscopic approach in ADPKD is attended with several difficulties. The key issues are lack of space for dissection and close relation of kidney with neighboring organs that increase the risk of iatrogenic injuries, diminished cardiopulmonary reserves of sufferers with questionable tolerance to prolonged pneumoperitoneum, associated coagulopathy in subjects with consequent risk of hemorrhage and transfusion requirements and need for large access for specimen retrieval. Several operators therefore opt for a hand-assisted laparoscopic approach in these scenarios. Hand-assisted laparoscopy violates several principles of pure laparoscopy and some operators are not comfortable with this approach. Hence, despite technical issues, some operators till date continue to undertake pure laparoscopic approach in these scenarios. [6],[8],[10] Gill et al. [8] reported 10 cases of synchronous BLN utilizing the retroperitoneal approach with intact specimen retrieval through infraumbilical midline incision. The outcome achieved was comparable to open synchronous bilateral nephrectomy. Although retroperitoneoscopy may be attempted in smaller kidneys, in oversize kidneys this approach is extremely demanding. Contrastingly transperitoneal approach has been successfully reported in the management of giant polycystic kidneys. [11] In view of the larger available working space with transperitoneal access, we practiced this approach in all our cases. In polycystic kidneys, multiple large cysts hinder dissection and access to the renal hilum. Few techniques have been advocated for facilitating space creation in these scenarios. Bendavid et al. [12] used a suction aspiration device to disrupt and aspirate the cysts for volume reduction whereas Sheshadri et al. [11] employed a powerful, 10-mm suction aspirator, with a beveled tip, that functions at 270 mm Hg pressure to reduce kidney size and facilitate safe hilar dissection. In early part of our cohort (2003-2006), progressive space creation by sequential deflation and aspiration of obstructing cysts mandated repeated change of equipments. The presence of multiple cysts made this procedure tedious and considerably delayed approach to renal hilum and gaining hilar control. In the later part of the series (2007 onwards), the usage of a special multifunctional device allowed this step to be conducted with considerable ease. Early hilar control could be achieved. This surely influenced reducing the procedural performance time in group II. Another technical modification that we consider to benefit procedure performance was utilization of additional ports in very large kidneys. Although laparoscopic nephrectomy conveniently performed using 3 or 4 ports, in oversize kidneys this may be insufficient. Bulky kidneys require excessive traction to facilitate dissection and hilar entry. Additional ports allowed traction at different angles. Pararenal dissection could be carried on faster, thereby facilitating achievement of early and satisfactory hilar entry. Occurrence of iatrogenic injuries secondary to excessive traction from limited ports was also avoidable. In Group II, despite larger renal dimensions, procedure performance duration was universally less than Group I. Usage of additional ports did not adversely affect morbidity parameters like postoperative pain perception or cosmesis. Early division of ureterogonadal pedicle in Group II also benefited operative performance. Division of this pedicle and cranial dissection using it as a fulcrum allowed early access to the renal hilum and renal pedicle. Following early hilar control, dissection of the devascularized renal unit could be carried out much more conveniently and rapidly, helping in reduction of total operation duration. These technical modifications also helped in reducing intraoperative blood loss. This was reflected in difference in postoperative drop in hemoglobin and postoperative transfusion requirements in two groups. Extraction of oversized specimens in polycystic kidneys has been mostly performed using large Pfannenstiel, midline or flank incisions. [10],[13],[14] This inflicts additional access-related morbidity like wound infection, retrieval site algesia, potential for wound herniation and suboptimal cosmesis. Thereby the goals of minimally invasive approach are defeated. In our cohort, patients in whom specimen was morcellated (Group II) reported a better morbidity profile. Also less time was expended for specimen extraction in this group and this also contributed to the shorter overall operative time in the latter part of the series. Even in oversize kidneys, morcellation could be completed uneventfully. Although there was no significant difference between two groups in analgesic need or postoperative analgesic score, all patients in Group II reported enhanced cosmesis. Additionally no patients in Group II experienced retrieval site morbidity. Due to presence of comorbidities, these patients have increased potential for operative and postoperative morbidity like cardiopulmonary morbidity, immediate or delayed hemorrhage, residual collections in the nephrectomy bed, postoperative peritonitis and sepsis, and deep vein thrombosis. Few operative and postoperative steps were diligently followed throughout our cohort. Intraperitoneal pressure during pneumoperitoneum was strictly regulated with close monitoring of end tidal carbon dioxide levels. During dissection all efforts were made to immediate aspirate the deflated cyst contents which often include infective material. Thereby intraperitoneal contamination was restricted. Additionally thorough peritoneal toileting was done. Meticulous attention was paid to achieve hemostasis. A wide bore drain was placed in all cases and drain removal was delayed till drain output was negligible. Postprocedure all patients were closely monitored in intensive care facility with early ambulation, chest physiotherapy, hemodialysis support and periodic evaluation of hemodynamic and coagulation parameters. All these collectively contributed in minimizing postoperative morbidity in our patients. This cohort is amongst the largest series of patients undergoing pure laparoscopic nephrectomy for ADPKD in ESRD on MHD currently reported from India. All procedures were performed by a single surgeon who was well versed with laparoscopic surgery. Moreover the operator was already conversant in laparoscopic nephrectomy in different scenarios prior to embarking on laparoscopic nephrectomy in these subsets of patients. In addition to technical modifications, increasing surgeon’s experience with this procedure also definitely influenced the procedure performance. More complex cases (larger renal units and simultaneous bilateral procedures) were selected for laparoscopy in Group II and could be completed successfully with improved operative and postoperative parameters.In summary, despite technical limitations, pure laparoscopic nephrectomy can be conducted in patients with ADPKD and ESRD on MHD with appreciable outcome. Technical modifications (use of multifunctional laparoscopic suction-hook, employment of additional ports and morcellation of extirpated specimen) coupled with increasing surgeon’s experience with the procedure enables conductance of this procedure in more complex cases without undue prolonged morbidity

Acknowledgment

• Mili Natekar for statistical analysis

References

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