Transperitoneal laparoscopic nephrectomy for giant hydronephrotic non-functioning kidney

Abstract

The Hydronephrotic kidney when containing more than 1 L of fluid is called giant hydronephrosis (GH). Ureteropelvic junction obstruction (UPJO), is the most common cause of GH. With routine antenatal ultrasound, UPJO and antenatal hydronephrosis are usually picked up and managed in the pediatric age group. Presentation of UPJO associated with GH is less common in adults. Majority of adults diagnosed with UPPJO and GH have loss of parenchyma and function of the affected kidney and nephrectomy will be the treatment of choice for such scenarios. Open simple nephrectomy has been described in the literature for treatment of GH, but few cases were reported managed with laparoscopic approaches. We present a case of laparoscopic transperitoneal nephrectomy in an adult with hydronephrotic non-functioning kidney containing 11 L of fluid. Case report A 54-year-old male patient presented with a complaint of progressive left-sided abdominal distension for the last ten years. Initially, the distension was not bothering the patient, but more recently, he starts to experience discomfort especially when laying down most probably due to pressure effect of the hugely hydronephrotic kidney on the adjacent organs and diaphragm. The abdominal distension was not associated with abdominal pain, renal colic, lower urinary tract symptoms, trauma, hematuria, loss of weight or appetite. Past surgical history was unremarkable. The general physical examination was grossly unremarkable. On abdominal examination, there was a notable sizeable abdominal distension; the left abdominal mass was occupying almost whole of the abdomen. The abdominal mass was non-tender on palpation, with a smooth surface and tense cystic in consistency. Work up including urine analysis, complete blood count, serum chemistries were within normal limits. Ultrasound of the abdomen and pelvis showed left-sided large hydronephrotic kidney occupying the whole of the abdomen from epigastrium to pelvis and normal right kidney. Contrast-enhanced computed tomography of the abdomen and pelvis showed massive left hydronephrotic kidney (28 cm x 26 cm x 22 cm) without appreciable renal parenchyma or contrast uptake (Fig. 1). The giant hydronephrotic kidney with a picture of UPJO was occupying the whole abdomen and extending down to the pelvis and pushing the adjacent structures to the right side of the abdomen. There were multiple stones of different sizes within the obstructed non-functioning kidney. There was no excretion of contrast on delayed films and no soft tissue masses within the kidney. The right kidney was unremarkable on the CT scan. The nuclear study showed non-functioning left kidney (Fig. 2). The diagnosis of left-sided massive hydronephrosis in a non-functioning kidney secondary to UPJO was established, and left-sided transperitoneal laparoscopic nephrectomy was done (Fig. 3). Open in a separate window Fig. 1 CT abdomen and pelvis, axial, coronal and sagittal views showing giant hydronephrotic left kidney occupying almost the whole abdomen.