|Year : 2020 | Volume
| Issue : 2 | Page : 68-73
Transperitoneal laparoscopic nephrectomy for benign nonfunctioning kidney: Our experience with 84 cases
Piyush Singhania1, Kush Shah1, Aman Agarwal1, Neeraj Tiwari2
1 Department of Urology, MGM Medical College and Hospital, Navi Mumbai, Maharashtra, India
2 Department of Surgery, Datta Meghe Institute of Medical Sciences, Wardha, Maharashtra, India
|Date of Submission||25-Apr-2020|
|Date of Acceptance||10-May-2020|
|Date of Web Publication||19-Jun-2020|
Dr. Kush Shah
Department of Urology, MGM Medical College and Hospital, Mumbai – Pune Hwy, MGM Campus, Kamothe, Panvel, Navi Mumbai 410209, Maharashtra.
Source of Support: None, Conflict of Interest: None
Background: The transperitoneal laparoscopic nephrectomy provides an optimal working space. It facilitates orientation by extending identifiable anatomic landmarks. The study evaluates the safety, outcome, and complications of the procedure. Materials and Methods: A total of 84 patients with benign nonfunctioning kidney admitted from April 1, 2015 to March 31, 2019 in the Department of Urology, MGM Medical College and Hospital, Navi Mumbai, India were considered for study purposes. The exclusion criteria of the study included uncorrected coagulopathy, active urinary tract infection, pregnancy, and severe cardiopulmonary disease. Preoperative imaging included digital X-ray, kidney ureter bladder, ultrasonography, intravenous pyelogram, computed tomography, intravenous urogram, micturating cystourethrogram, and diethylenetriaminepentaacetic acid renal scan. All operated patients were evaluated for intraoperative and postoperative complications. Results: The mean age of patients was 40.76 years. Of 84 patients, 60 were men and 24 were women. Patients had complaints of ipsilateral flank pain 76 (90.47%), lower urinary tract symptoms 34 (30.95%), and hematuria 18 (21.42%). Causes of benign nonfunctioning kidney were obstructive uropathy secondary to stone in 62 patients (73.81%) followed by neglected pelvic ureteric junction obstruction in 8 (9.53%), renal tuberculosis in 6 (7.14%), chronic pyelonephritis in 6 (7.14%), and renovascular hypertension in 2 (2.38%) patients. Seven patients required conversion to open surgery, secondary to adhesions in four patients, instrument failure in one case, and bleeding in two cases. The mean stay of the patient in the hospital was 4.38 days. Various types of complications occurred in five patients: colonic injury in one, wound infection in three, and incisional hernia in one. Conclusion: Transperitoneal laparoscopic nephrectomy is an effective procedure with minimal morbidity, hospital stay, rapid recovery, and better cosmesis making this the gold standard technique for nephrectomy.
Keywords: Nephrectomy, nonfunctioning kidney, pyelonephritis, renal calculi
|How to cite this article:|
Singhania P, Shah K, Agarwal A, Tiwari N. Transperitoneal laparoscopic nephrectomy for benign nonfunctioning kidney: Our experience with 84 cases. MGM J Med Sci 2020;7:68-73
|How to cite this URL:|
Singhania P, Shah K, Agarwal A, Tiwari N. Transperitoneal laparoscopic nephrectomy for benign nonfunctioning kidney: Our experience with 84 cases. MGM J Med Sci [serial online] 2020 [cited 2020 Aug 15];7:68-73. Available from: http://www.mgmjms.com/text.asp?2020/7/2/68/287168
| Introduction|| |
Kidneys like other body organs are vulnerable to many threats such as infections, trauma, tumors, the stone formation, vascular problems, and obstruction to drainage. Various benign diseases that may lead to nonfunctioning kidney include neglected urolithiasis/stone disease, chronic pyelonephritis, neglected pelviureteric junction obstruction, renovascular hypertension, renal tuberculosis, xanthogranulomatous pyelonephritis, and emphysematous pyelonephritis. Treatment of a benign nonfunctioning kidney is a simple nephrectomy. Previously, surgical options to the urologist for treatment of benign nonfunctioning kidney were limited to open surgical techniques. In recent years, interest in nephrectomy by minimally invasive techniques has increased and many authors have shown that nephrectomy by these techniques is associated with fewer complications and shorter hospital stay., Clayman et al. performed the first laparoscopic nephrectomy for a 3-cm renal mass in an elderly patient.
There are two basic laparoscopic approaches for simple nephrectomy: retroperitoneal and transperitoneal. A third approach, the hand-assisted technique, attempts to bridge the gap between laparoscopic and open surgery and may help surgeons without advanced laparoscopic training. The transperitoneal route is the most common method used to perform laparoscopic surgery because it affords an optimal working space and facilitates orientation by providing readily identifiable anatomic landmarks. The retroperitoneal access allows a procedure without manipulation of the intraperitoneal organs, reducing the risk of direct and indirect damage to these structures. In addition to reducing the incidence of adynamic ileus and adhesions, the retroperitoneal access keeps the peritoneal cavity isolated from urinary fistulas and postoperative infectious processes. This access also enables early control of the renal pedicle, which can result in a major advantage in the case of inflammatory renal disease.,
Laparoscopic nephrectomy has proven to be beneficial as compared to open surgery in terms of lesser postoperative pain, a shorter hospital stay, reduced convalescence, and a more rapid return to full activity., With growing expertise and experience, current operative times have decreased dramatically and are comparable to those in the open group.,
| Materials and methods|| |
A prospective observational study was conducted in the department of urology in our institute. A total of 84 consecutive patients admitted under the department of urology, who were scheduled to undergo laparoscopic transperitoneal simple nephrectomy with split renal function <10%, glomerular filtration rate (GFR) <10 mL, and willing to give the consent, were included in our study from May 1, 2015 to April 31 2019. The exclusion criteria of the study included uncorrected coagulopathy, active urinary tract infection (UTI), pregnancy, and severe cardiopulmonary disease. Patients were informed regarding the aims and objectives of the study and a detailed informed written consent was taken from the patients. In the case of a minor, <18 years of the age, consent from the parent was taken and assent from the patient was taken before the inclusion of the patient into the study. Complete detailed history regarding symptoms, past history, relevant history pertaining to etiological factors and family history were taken. Complete blood cell count, serum creatinine, serum electrolytes, urine routine microscopy, and culture sensitivity were performed in all the patients. Preoperative imaging modalities included digital X-ray, kidney ureter bladder (KUB), ultrasonography, intravenous pyelogram, computed tomography (CT) intravenous pyelogram, micturating cystourethrogram, and diethylenetriaminepentaacetic acid (DTPA) renal scan. All the patients were posted for laparoscopic transperitoneal simple nephrectomy if the split renal function of the kidney was <10% or <10 mL GFR. Oral anticoagulants and antiplatelet drugs were stopped at least a week before surgery and if required the patient was put on short-acting agents such as heparin. Patients were informed of all risks, benefits, and alternatives to the procedure. All the patients were informed of the possibility of converting to an open surgery. All the patients were subjected to laparoscopic transperitoneal simple nephrectomy under strict aseptic measures.
Patients were given three teaspoons of lactulose syrup on the night before surgery. All patients were subjected to general anesthesia. Nasogastric tubes and a Foley catheter were placed to decompress the stomach and bladder, respectively. The patients were then placed in a lateral decubitus position, with the pathologic kidney away from the table and kidney bridge of the OT table elevated to open the flank.
A 10-mm trocar was placed pararectally superior to the umbilicus. A second trocar was placed in the midclavicular line subcostal and a third trocar was placed near the midpoint of the spinoumbilical line. A fourth 5-mm trocar was placed along the posterior axillary line [Figure 1] for retraction of the kidney if required. On the right side, the liver was retracted upward using the fifth epigastric 5-mm port and Allis clamp which held the lateral abdominal wall. The colon was reflected medially and the kidney was exposed. The ureter was identified and dissected. Hilar dissection was performed. Renal artery and vein were clipped separately with double hem-o-lok clips and divided [Figure 2]. Lateral and superior attachments of the kidney were divided and ureter was clipped and divided. The specimen was delivered either through a separate incision in the iliac fossa or through a 10-mm port incision. The port sites were closed in layers and dressing was carried out.,
All operated patients were evaluated for preoperative complaints, intraoperative, and postoperative complications.
| Results|| |
The mean age of cases was 40.76 years with a standard deviation of 14 years. Males accounted for 71.42% of cases, whereas females were 28.58% [Table 1]. The right-side involvement was seen in 50 (59.52%) cases, whereas the left-side involvement was seen in 34 (40.48%) cases. The majority of cases (90%) had complaints of ipsilateral flank pain as their presenting complaint followed by lower urinary tract symptoms (LUTS) (31%) and hematuria (21%). Majority of patients (64[73.81%]) in our study were having benign nonfunctioning kidney secondary to obstruction due to stone and related complications (chronic pyelonephritis and pyonephrosis). Other causes for a benign nonfunctioning kidney in our study were neglected pelviureteric junction obstruction (9.53%), renal tuberculosis (7.14%), chronic pyelonephritis due to causes other than stones (7.14%), and renovascular hypertension (2.38%) [Table 2]. In our study, the approach was transperitoneal in all cases. Approximately 73.81% of cases had <100 mL of blood loss during the operative procedure with a mean blood loss of 85.24 mL [Table 3]. The mean operative time required for the laparoscopic nephrectomy was 113 min. Operative time was more in cases of previous surgery and the presence of adhesions and accessory vessels (P = 0.005). All operations were completed successfully, with seven cases (8.3%) requiring conversion to open nephrectomy. The reasons for conversion were failure to progress secondary to adhesions and difficult hilar dissection (four cases), instrument malfunction (one case), and bleeding (two cases). The mean hospital stay of our cases after surgery was 4.38 days [Table 4]. The hospital stay was more in patients who required conversion to open and the association was significant. (P = 0.006). Postoperative complications occurred only in five (5.95%) patients [Table 5]. One patient had a major complication in the form of colonic injury, three cases had minor complications in the form of superficial wound infection, and one case had incisional hernia.
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|Table 1: Age- and sex-wise distribution of benign nonfunctioning kidney disease|
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| Discussion|| |
The surgical management of benign nonfunctioning kidney disease has changed dramatically over the last 20 years as a result of technological advances. It was seen in our study that more cases had involvement of the right side with a frequency of 50 (59.5%) and the left-side involvement was seen in 34 (40.48%) cases. In a study by Rafique, 65 (55%) of 118 patients had the right-sided nonfunctioning kidney and the remaining had left-the sided nonfunctioning kidney. Shah et al. carried out a prospective study in 2012–2013, in which 35 cases had a left-sided disease and 32 had a right-sided disease.
The majority of cases (90%) had complaints of ipsilateral flank pain as their presenting complaint followed by LUTS (31%) and hematuria (21%). In a similar study, 72% of cases presented with ipsilateral flank pain followed by ipsilateral flank pain and fever (5%). In a study conducted by Andualem et al., the most common presenting symptom was loin pain in 100% followed by hematuria in 43.5% and abdominal or flank mass in 35.6% of the cases.
Twenty-six (31%) patients had a history of abdominal and renal surgeries in the past. These cases dealt with the repositioning of ports to avoid previous scars and were associated with longer operative time and technical difficulty. There was no associated increase in intraoperative blood loss, conversion to open, or increase postoperative complications but we required a longer time to complete the procedure. These findings were very much similar to the study conducted by Parsons et al. Aminsharifi et al. compared the surgical results of laparoscopic transperitoneal simple nephrectomy between patients who had or had not renal surgery before. The patients with previous renal surgery had significantly longer operation time. All other parameters such as hospitalization time, blood loss, preoperative and postoperative complications, and open conversion rates were similar.
Majority of patients (64[73.81%]) were having benign nonfunctioning kidney secondary to obstruction due to stone and stone related complications (chronic pyelonephritis and pyonephrosis). Our results were comparable with the series reported from developing countries such as Pakistan, Jordan, Saudi Arabia, and Sudan. India is located in the stone belt area and renal stone disease remains a major problem. Laparoscopic nephrectomy in patients with the renal stone disease is also often complicated by perirenal adhesions formed secondary to previous episodes of pyelonephritis, pyonephrosis, or previous open renal surgery, which makes dissection difficult. Tepeler et al. also compared the results of laparoscopic surgery in kidneys with and without stones and they reported that the only difference was operation time. Tuberculous kidneys were considered as a relative contraindication for laparoscopic nephrectomy previously. In our study of 42 cases, three (7.1%) patients had nephrectomy for renal tuberculosis. The studies from Pakistan, Jordan, and India have shown that renal tuberculosis accounted for 7.6%, 10.8%, and 3% nephrectomy performed for benign conditions, respectively. Tuberculosis remains a major health problem in India and this study reveals that there is a much higher incidence of renal tuberculosis compared with other countries. Other causes for the nonfunctioning kidney in our study were neglected pelviureteric junction obstruction (9.53%) and chronic pyelonephritis (7.14%). In a similar study, chronic pyelonephritis (nonstone related) and neglected ureteropelvic junction obstruction were the causes of nonfunctioning kidney in 20% and 16% of cases, respectively. The prevalence of renovascular hypertension in our study was 2.38% of cases. The importance of treating renovascular hypertension lies in the fact that the cause is identifiable and reversible with surgery, which reduces the need for lifelong medical treatment.
Twenty percent of patients had accessory renal vessels, mostly lower polar vessels. In our study, we found that it took a long time to complete the surgery in the presence of perirenal adhesions and renal hilar vascular anomalies. In a similar study, which compared the results of laparoscopic surgery in kidneys with and without stones, they reported that the only difference was operative time due to the presence of dense fibrotic tissue around the hilum.
Sixty-four (74%) cases had <100 mL of blood loss during the operative procedure. The minimum blood loss was about 50 mL and maximum blood loss was approximately 180 mL. There was no significant hemoglobin drop in the postoperative period and none of our cases required blood transfusion during or after the procedure. Kurt et al. reported the blood loss during the procedure to be 72.2 ± 104.4 mL in noninflammatory diseases and 105.0 ± 133.1 mL in inflammatory causes of a nonfunctioning kidney. The study of Forde et al. showed the mean operative blood loss in the laparoscopic group (65 mL [range 50–200] vs. 351 mL [50–1740]) in the open nephrectomy group. These studies show that the blood loss is negligible in laparoscopic nephrectomy.
The mean operative time required for laparoscopic nephrectomy was 113 min with 34 min as standard deviation. The minimum operative time was 70min and the maximum time required was 186 min. The study by Phillips et al. had a mean operative time of 150min (130–180). In another study by Eraky et al. the operating time was 186 min (range 75–420).
The mean hospital stay of patients was 4.38 days with a standard deviation of 1.62, whereas the minimum was 3 days and the maximum was 10 days. It has been observed that the eight cases converted to open had a longer recovery time, higher analgesic requirement, more blood loss, and a longer stay in hospital (8–10). Similar to our study, Forde et al.’s study showed that the mean hospital stay was 3.9(3–6) days in the laparoscopic group and 6.5 (5–11) days in an open nephrectomy group. In a study by Eraky et al., the mean hospital stay was 2.9 days (range 2–12).
All operations were completed successfully, with seven cases (8.3%) requiring conversion to open nephrectomy. The reasons for conversion were failure to progress secondary to adhesions (four cases), instrument malfunction (in one case), and bleeding (two cases). Phillips et al., the study had a conversion rate of 6%, reasons being a failure to progress are secondary to adhesions (in three cases), uncontrollable hemorrhage (two cases), and IVC trauma (one case). A similar observation was also reported by other investigators.
Postoperative complications occurred only in five (5.95%) patients, of which one was major and four were minor complications. Keeley and Tolley reported that the overall complication rate of laparoscopic nephrectomy in their series was 18%, of which 3% were major and 15% were minor complications.
There was one major complication in the form of colonic injury. The case was converted to open during nephrectomy due to dense perirenal adhesions and the surgery was completed through a flank incision. There was a small perforation in the ascending colon. A two-layered closure beginning with a run of 3-0 absorbable sutures and an outer layer of interrupted seromuscular 3-0 silk suture was performed. The patient recovered uneventfully and was discharged from the hospital after 7 days of surgery.
Wound infections were superficial in three cases and were treated by oral antibiotics and daily dressing. One of our patients developed an incisional hernia for which primary repair was performed.
| Conclusion|| |
Transperitoneal laparoscopic nephrectomy is a safe and effective procedure. It is associated with minimal morbidity and significant advantages in terms of reduced postoperative pain, shorter hospital stay, rapid convalescence, and better cosmesis making this the gold standard technique for nephrectomy. Once considered contraindication, patients with nonfunctioning kidney due to renal tuberculosis, pyonephrosis, and chronic pyelonephritis are being successfully managed by laparoscopic simple nephrectomy.
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Conflicts of interest
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[Figure 1], [Figure 2]
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]