ENDOUROLOGY & LAPAROSCOPY

Limitations of Laparoscopy for Bilateral Nephrectomy for Autosomal Dominant Polycystic Kidney Disease
Lipke MC, Bargman V, Milgrom M, Sundaram CP
Department of Urology, Indiana University School of Medicine, Indianapolis, Indiana 46202-5289, USA
J Urol. 2007; 177: 627-31

• Purpose: We retrospectively studied outcomes following bilateral hand assisted laparoscopic nephrectomy.
• Materials and Methods: We retrospectively reviewed the charts of 18 patients with symptomatic autosomal dominant polycystic kidney disease who underwent bilateral hand assisted laparoscopic nephrectomy. Preoperative radiographic imaging was reviewed retrospectively to determine kidney size based on an ellipsoid shape. A visual analog pain scale with scores of 0 to 10 to assess pain related to autosomal dominant polycystic kidney disease was measured preoperatively and postoperatively.
• Results: Average patient age was 48.2 years (range 30 to 64). Of the patients 14 successfully underwent bilateral hand assisted laparoscopic nephrectomy, while 4 required open conversion. A total of 16 patients underwent nephrectomy for pain and 2 underwent surgery for frequent recurrent symptomatic urinary tract infections. All patients except 1 underwent renal transplantation before bilateral nephrectomy. There was a significant difference in the volume of the right and left kidneys between the hand assisted laparoscopic and open groups (mean +/- SD 1,043 +/- 672 and 1,058 +/- 603.8 vs 4,052 +/- 548 and 3,592 +/- 1,752 cm (3), p < 0.001 and 0.06 respectively). There were 5 complications, including wound infection and protracted ileus in 2 patients each, and incisional hernia in 1. In addition, the difference in mean preoperative and postoperative visual analog pain scores was statistically significant (6.9, range 3 to 10 and 0.5, range 0 to 2, p < 0.05).
• Conclusions: Bilateral laparoscopic hand assisted nephrectomy is a safe and reliable option in patients requiring removal of the 2 kidneys in a single setting. Rather than performing staged nephrectomies, hand assisted laparoscopic nephrectomy allows the single administration of general anesthesia and provides effective relief of bothersome symptoms in patients with symptomatic autosomal dominant polycystic kidney disease. This procedure is safe in patients with renal transplants. Patients with massive polycystic kidneys with a kidney volume of greater than 3,500 cc are at increased risk for open conversion and they may have improved outcomes if open nephrectomy is attempted from the outset.
  
  
• Editorial Comment
  The new era of minimally invasive surgery demonstrates the feasibility of bilateral nephrectomies performed laparoscopically. There are no more questions that patients recover faster with better outcomes than the open counterpart is. Moreover, this less invasive approach allows patients to undergo 2 procedures in one setting providing innumerous benefits to patients that in the past had to experience staged operations. The authors demonstrated limitations to the technique when the polycystic kidneys are massively large decreasing the working space.

Dr. Fernando J. Kim
Chief of Urology, Denver Health Med Ctr
Assistant Professor, Univ Colorado Health Sci Ctr
Denver, Colorado, USA