Nephrectomy For Polycystic Kidney Disease Research Articles

Video 8 - Right nephrectomy for Polycystic Kidney Disease; Demonstration of a laparoscopic technique, a video presentation

Video 8 - Right nephrectomy for Polycystic Kidney Disease; Demonstration of a laparoscopic technique, a video presentation

Laparoscopic nephrectomy for polycystic kidney disease: Benefit or necessity?

Background. According to foreign and domestic authors, autosomal dominant polycystic kidney disease (ADPKD) is a disease accompanied by a progressive deterioration in the functional state of the kidneys and occupies a significant contribution to the structure of all causes leading to the end stage of chronic renal failure (ESRD). An increase in the volume of the kidneys and the development of complications significantly worsen the quality of life of these patients. Open surgical interventions are accompanied by a more severe course. In this connection, the question of choosing the timing and method of surgical intervention in this group of patients remains relevant.
 Aim. To evaluate the results of nephrectomy in patients with ADPKD for the period from 2016 to 2022, performed at the Krasnoyarsk Regional Clinical Hospital.
 Materials and methods. Within 6 years, 22 nephrectomies were performed in 20 patients with ADPKD. Monolateral nephrectomy was performed in 12 cases, simultaneous bilateral surgery was performed in eight patients. The mean age of the patients was 51.3±7.9 years. Mostly nephrectomy was performed by laparoscopic approach (17 patients), lumbotomy operation was performed in three patients. The need for conversion during laparoscopic operations was not noted.
 Results. Open surgical treatment was performed only because of uncontrolled gross hematuria and suppuration of cysts. All patients were transferred to the intensive care unit after surgery. Repeated surgery due to the development of bleeding was required in 33.3% of cases. The need for an inpatient stage of treatment was 15.1±2.8 days. In one case, a fatal outcome was recorded. Laparoscopic nephrectomy was performed in 17 patients, monolateral in seven patients, staged bilateral in two, and simultaneous bilateral in eight patients. In 41% of cases, in addition to pain and hypertension, nephrectomy was due to the upcoming kidney transplantation. The average volume of removed kidneys was 3138.74±356.30 ml. The average bed-day was 8.86±2.4 days.
 Conclusion. The increase in the number of patients with ADPKD and ESRD raises the question of the improvement in their quality of life that can be achieved by unilateral or bilateral nephrectomy. However, there are no clearly regulated criteria that determine the indications for these types of surgery. Despite certain difficulties, we believe that laparoscopic nephrectomy in patients with ADPKD and ESRD is the most optimal.

Renal Neoplasia in Polycystic Kidney Disease: An Assessment of Tuberous Sclerosis Complex–associated Renal Neoplasia and PKD1/TSC2 Contiguous Gene Deletion Syndrome

To determine the incidence of renal neoplasia among patients undergoing nephrectomy for polycystic kidney disease (PKD), we queried our institutional nephrectomy registry (years 2000–2020). Approximately 4% (231 of 5757) of patients who underwent nephrectomy had PKD, and 26 of these 231 patients (11.3%) had renal neoplasia. Tumors from an additional two patients with PKD were also evaluated. Patients with PKD who had tuberous sclerosis complex (TSC)-associated renal neoplasia were screened for PKD1/TSC2 contiguous gene deletion syndrome (CGS) using single nucleotide polymorphism arrays. The median age of patients with PKD and renal neoplasia at nephrectomy was 54 yr. The median tumor size was 2.0 cm and the tumors were predominantly of low grade and stage. The tumors consisted of 23 renal cell carcinomas (RCCs), one epithelioid angiomyolipoma, and four angiomyolipomas. The median follow-up was 59.5 mo (n = 26) and only one patient with clear cell RCC developed metastases. Two patients with angiomyolipomas had PKD1/TSC2 CGS. Our results support screening of patients with PKD and TSC-associated renal neoplasia as well as TSC patients with cystic renal disease for CGS, as identification of patients with CGS can better define the manifestation and prognosis of CGS and guide counseling regarding patterns of inheritance. Patient summaryWe identified patients with abnormal kidney cell growth (called renal neoplasia) among those undergoing removal of kidney tissue for polycystic kidney disease (PKD) and patients with a syndrome involving deletions in two genes, called PKD1/TSC2 contiguous gene deletion syndrome (CGS) at our institution. Of 231 PKD patients with removal of kidney tissue, 11.3% had renal neoplasia, and two patients with angiomyolipoma tumors had PKD1/TSC2 CGS. Detection of renal neoplasia associated with a condition called tuberous sclerosis complex in PKD may increase the identification of patients with PKD1/TSC2 CGS and guide patient counseling regarding outcomes and patterns of inheritance.

Survival outcomes for patients with surgically induced end-stage renal disease.

While medically induced end-stage renal disease (m-ESRD) has been well-studied, outcomes in patients with surgically induced ESRD (s-ESRD) are unknown. We sought to quantitatively compare the non-oncological outcomes for s-ESRD and m-ESRD in a large, population-based cohort. Medicare patients >65 years old initiating hemodialysis were identified using the U.S. Renal Data System database (2000-2012). Metastatic cancer, prior transplant history, and nephrectomy for polycystic kidney disease were exclusion criteria. Patients were classified as having s-ESRD or m-ESRD based on hospital and physician claims for nephrectomy within a year preceding the onset of maintenance hemodialysis. Outcomes included non-cancer mortality (NCM), overall survival (OS), cardiovascular event (CVE), and renal transplantation. Time-to-event analyses were performed using Kaplan-Meier and cumulative incidence curves, and multivariable Cox and Fine-and-Grey regression models. The cohort included 312 612 patients, of whom 1648 (0.53%) had s-ESRD. Compared to m-ESRD patients, s-ESRD patients had a significantly lower five-year cumulative incidence of NCM (68% vs. 80%; p<0.001) and CVE (62% vs. 68%; p<0.001), with a correspondingly higher probability of OS (22% vs. 17%; p<0.001) and rate of renal transplantation (3.6% vs. 2.0%; p<0.001). On multivariable analyses, s-ESRD remained associated with lower risks of NCM (p<0.001) and CVE (p<0.001), improved OS (p<0.001), and higher chance of renal transplantation (p<0.001). While outcomes for s-ESRD appear more favorable than m-ESRD, s-ESRD is still associated with a substantial risk of NCM and CVE, and a low incidence of renal transplantation in Medicare patients >65 years old. These non-oncological outcomes are worth considering in patients potentially facing postoperative ESRD.

65 Adrenal Insufficiency After Bilateral Nephrectomy for Polycystic Kidney Disease

65 Adrenal Insufficiency After Bilateral Nephrectomy for Polycystic Kidney Disease

Off-Clamp Robotically-Assisted Partial Nephrectomy in Polycystic Kidney Disease

Abstract Introduction: Partial nephrectomy (PN) in autosomal dominant polycystic kidney disease (PCKD) is desirable in the setting of chronic kidney disease, but presents a technical challenge beca...

Kidney Transplantation With and Without Native Nephrectomy for Polycystic Kidney Disease: Results of the National Inpatient Sample and the Rationale for a 2-Staged Procedure

Polycystic kidney disease (PKD) is one of the most common causes of end-stage renal disease requiring hemodialysis or transplantation. In patients requiring transplantation, there are several indications for native nephrectomy, including recurrent cyst infection, bleeding, or to provide room for the graft. There is disagreement about whether it is advisable to perform kidney transplantation alone (KT), or to perform KT with simultaneous native nephrectomy (KTN). We compared postoperative outcomes of KTN and KT in a large national cohort. The Nationwide Inpatient Sample (NIS) between 2000 and 2014 was examined for a diagnosis of PKD with evidence for KT or KTN. Logistic regression, adjusting for age, sex, comorbidity, and hospital region, was used to compare groups for the need for blood transfusion, need for critical care interventions, and development of postoperative complications. A total of 4,003 hospitalizations were identified, which was representative of 19,302 weighted discharges nationally. In adjusted logistic regression models, KTN demonstrated significantly higher risk for blood transfusion (odds ratio [OR] 2.06; 95% CI 1.44 to 2.96; p < 0.0001), postoperative complications (OR 1.44; 95% CI 1.05 to 1.96; p= 0.02), and critical care interventions (OR 1.44; 95% CI 1.07 to 1.95; p= 0.02). Other significant predictors for blood transfusion included female sex (OR 1.76; 95% CI 1.45 to 2.13; p < 0.0001), age older than 61 years (OR 1.60; 95% CI 1.21 to 2.10; p= 0.001), and Charlson comorbidity score ≥2 (OR 1.52; 95% CI 1.10 to 2.09; p= 0.01). Among patients with PKD, in comparison with KTN, KT alone represents a decreased risk for negative postoperative outcomes. A 2-staged procedure should be considered, when feasible, to minimize adverse patient outcomes.

53 Laparoscopic nephrectomy for polycystic kidney disease: Comparison of the transperitoneal and retroperitoneal approaches

53 Laparoscopic nephrectomy for polycystic kidney disease: Comparison of the transperitoneal and retroperitoneal approaches

Néphrectomie laparoscopique pour reins polykystiques : principes et résultats

To evaluate the feasibility and morbidity of laparoscopic nephrectomy in patients with autosomal dominant polycystic kidney disease (ADPK). This is a retrospective multi-centre study (University Hospitals of Lyons, Toulouse, Nantes and Rennes). Sixty-eight patients who had undergone laparoscopic nephrectomy for polycystic kidney disease between November 1999 and May 2009 were included. This involved unilateral nephrectomy 64 cases, one-stage bilateral in one case and two-stage bilateral in three cases. The mean operating time was 218±74min (100-420) Conversion was necessary in 7 cases. The mean weight of the removed kidney was 1291±646g (240-3400). We regret to report 20 postoperative complications, including one death on postoperative day 50, following an abscess in the renal pelvis, 6 retroperitoneal haemoatomas and 5 arteriovenous fistula thromboses. Postoperative analgesia involved PCA treatment with morphine for a mean period of 1.59±0.8 days (0.5-4). The mean length of hospital stay was 8.3±6.1 days (3-50). This study shows the feasibility of the laparoscopic approach for nephrectomy in ADPK. This procedure should be performed by experienced laparoscopic surgeons. Indeed, the complication rate is moderate but there is still a risk of severe complications. 5.

Simultaneous Kidney Transplantation and Bilateral Native Nephrectomy for Polycystic Kidney Disease

Bilateral native nephrectomy with simultaneous kidney transplantation is becoming more common for patients with polycystic kidney disease in the living donor nephrectomy era. Single center reports evaluating the short-term and long-term outcomes of simultaneous kidney transplantation have been published but are generally limited by small sample sizes. We examined population level data to broadly define the complications of simultaneous kidney transplantation. The Nationwide Inpatient Sample (NIS) was used to acquire data on 2,368 patients with polycystic kidney disease treated with bilateral native nephrectomy between 1998 and 2010. We performed unadjusted, multivariable and propensity score adjusted analyses of postoperative outcomes. A total of 2,368 patients were included in this study. The 271 patients (11.4%) who underwent simultaneous kidney transplantation had higher rates of intraoperative hemorrhage, blood transfusion and urological complications (propensity score adjusted OR 3.3, p=0.01, OR 4.2, p<0.0001 and OR 5.5, p<0.0001, respectively) but a lower in-hospital mortality rate (15.8% vs 1.1%, propensity score adjusted OR 0.10, p<0.0001). Median hospitalization was also significantly higher in patients who underwent simultaneous kidney transplantation (6 vs 9 days, p<0.0001). For the top quartile of high volume hospitals the rates of intraoperative hemorrhage, blood transfusion and urological complications remained statistically higher in patients treated with simultaneous kidney transplantation but in-hospital mortality was similar on multivariable logistic regression (OR 0.2, p=0.17). Except for increased rates of intraoperative hemorrhage, blood transfusion and urological complications there were no significant differences in postoperative adverse outcomes in this large, population based study of patients who underwent simultaneous kidney transplantation compared to bilateral native nephrectomy alone.

Urologische Betreuung von Patienten vor und nach Nierentransplantation

Patients with end-stage renal disease awaiting kidney transplantation require regular urological evaluation. The urologist's main task is early diagnosis and treatment of genitourinary malignancies and evaluation of the lower urinary tract. Furthermore, urologists are often confronted with the question of whether or not to perform pretransplant urological surgery, i.e., native nephrectomy for polycystic kidney disease. Urological care after kidney transplantation involves diagnosis and treatment of ureteral complications, malignancies, lower urinary tract symptoms, and last but not least erectile dysfunction, which has a prevalence of 20-50% among kidney transplant recipients. For the evaluation and follow-up of the living kidney donor, international guidelines have been developed in recent years to also help the urologist to perform a correct evaluation and follow-up of the kidney donor.

END STAGE POLYCYSTIC KIDNEY DISEASE: INDICATIONS AND TIMING OF NATIVE NEPHRECTOMY RELATIVE TO KIDNEY TRANSPLANTATION

A49 Aims: We evaluated indications and outcome of pre-transplant, concomitant and post-transplant native nephrectomy in patients with end stage polycystic kidney disease (PCKD). Methods: The records of 32 patients were retrospectively reviewed using our institution’s electronic database. Results: Between Jan. 1992 and Dec. 2002, 171 patients with end stage PCKD received a kidney transplant at our institution. Among those, 32 patients underwent either pre-transplant (A) concomitant (B) or post-transplant (C) native nephrectomy. Bilateral nephrectomy was performed in 25 patients. Mean follow-up was 23.3 months. In group A (n = 7) indications for nephrectomy were hematuria, a renal mass and chronic pain. In B (n = 16) lack of space was the main indication. In C (n = 9) the main indication was urinary tract infection. Operating time was 231±14 min (A) vs. 370±24 min (B) vs. 208±14 min (C) [P = 0.001]. Intraoperative blood loss was 533±105 ml (A) vs. 573±155 ml (B) vs. 522±181 ml (C) [P = n.s.]. In group B two patients required blood transfusions. Perioperative complications included a wound dehiscence (A) and abdominal bleeding (C). Hospital stay was comparable between groups: 7±0.7 days (A), 8.6±1.2 days (B) and 6.3±0.6 days (C) [P = n.s.]. At 3 months, serum-creatinine was not significantly different between group B and C: 1.3±0.1mg/dl vs. 1.5±0.2 mg/dl. Conclusions: Unilateral or bilateral nephrectomy of polycystic kidneys at the time of transplantation has a low complication rate and does not increase patient morbidity. Postoperative graft function is excellent. We therefore perform concomitant native nephrectomy whenever indicated. INDICATIONS FOR NATIVE NEPHRECTOMY IN PCKD PATIENTS Pre-transplant: hematuria requiring transfusions / renal mass >> bilateral nephrectomy Concomitant: lack of space for kidney graft / chronic pain >> unilateral or bilateral nephrectomy chronic infection / hematuria >> bilateral nephrectomy Post-transplant: de novo infection / renal mass / hematuria / chronic pain >> bilateral nephrectomy