Laparoscopic Management of Page Kidney

Abstract

A 15-year-old white male was found to have significant hypertension on an annual athletic physical examination conducted elsewhere. Severe hypertension was documented on several occasions, with systolic blood pressure in the 160 to 170 mm. Hg range. The patient was initially treated with oral antihypertensives unsuccessfully. Extensive workup included abdominal computerized tomography (CT), which revealed a large right subcapsular renal fluid collection with parenchymal compression (fig. 1). The patient underwent percutaneous drainage of the fluid collection, with temporary resolution of the hypertension for approximately 1 month. However, the hypertension returned, and followup CT demonstrated re-accumulation of the subcapsular renal fluid, prompting referral to our institution. Preoperative imaging consisted of renal ultrasound and captopril mercaptoacetyltriglycine renal scan. The sonogram confirmed an 11.4 5.2 3.2 cm. subcapsular anechoic mass along the right kidney consistent with a fluid collection with compression of the renal parenchyma. In addition, a linear area consistent with renal parenchymal scar from a probable previous laceration was diagnosed. The nuclear medicine scan showed slight delay and decreased perfusion of the right kidney. Laboratory studies were unremarkable except for increased peripheral renin activity. Retroperitoneoscopy using a Hasson cannula approach with balloon dilation was performed. The densely involved fibrotic external renal capsule was excised and the subcapsular fluid collection was drained (fig. 2). In addition, the fibrotic reaction compressing the normal parenchyma was incised to relieve any chronic compressive component. An argon beam laser was used to eradicate residual fibrotic scar and maintain hemostasis. Operative time was 240 minutes, blood loss was minimal and hospital stay was 43 hours. Immediately following the procedure, the patient’s blood pressure decreased to the normal range for his age. He remained normotensive off any medication during 10 months of followup. Followup ultrasound revealed a normal appearing appropriate sized kidney.