The aim of this study was to re port our ex pe ri -ence with the llaparoscopic transperitoneal treat -ment of sim ple re nal cysts, to an a lyze the im me -di ate and long-term clin i cal out comes, and toeval u ate the ef fi cacy and safety of this miniinva-sive sur gi cal tech nique. Be tween 2009 and 2014we di ag nosed and treated a to tal of 48 pa tientswith symp tom atic sim ple re nal cysts. The di ag no -

sis was set up by ul tra sound (US) and/or com puted to -mog ra phy (CT) ex am i na tion. All cases were man agedby transperitoneal lap aro scopic cyst decortication.De mo graphic data, perioperative blood loss, du ra tionof op er a tive pro ce dure, length of hos pi tal stay andperi- and post op er a tive com pli ca tions were an a lyzed.Fol low-up in cluded clin i cal ex am i na tion and re nal US,per formed at 3-monthly in ter vals dur ing the first year and yearly there af ter. Pa tient age ranged from 32 to68 years (mean age 52.4 years). 27(56.2%) of the pa -tients were males and 21(43.8%) - fe males. 42(87.5%)of the cysts were pe riph eral, and 6(12.5%)–peripel-vic; 28(58.3%) were lo cal ized to the left and 20(41.7%) – to the right; and they ranged by size from 5to 30 cm (mean 9.8 cm). 45 (93.8%) of the cysts wereiden ti fied as cat e gory I, and only 3 (6.2%) - as catego- ry II, ac cord ing to the Bosniak clas si fi ca tion. None ofthe cases re quired con ver sion to open sur gery. Therewere no peri- and post op er a tive com pli ca tions. Theav er age du ra tion of the lap aro scopic pro ce dure was55min, and the av er age perioperative blood loss - 50mL. All pa tients had neg a tive cy to log i cal and histolo-gical find ings in dic a tive for ma lig nancy. The fol low-up pe riod ranged from 5 to 52ain months (av er age -25.4 months). In 47cases (97.9%)exellent ther a peu ticre sults were re ported: com plete re lief of clin i calsymp toms, fast re cov ery of phys i cal ac tiv ity and pa -tient qual ity of life. There were three re cur rences(6,2%) met in pa tients with mul ti ple cysts, but onlyone of them re quired re peated sur gery. Lap aro scopictransperitoneal decortication is a miniinvasive, highlyef fec tive and safe method of treat ment of symp tom -

atic re nal cysts. The im me di ate re lief of clin i calsymp toms, the short pe riod of reconvalescence, theex cel lent qual ity of life af ter sur gery, and the low re -lapse rate con fi dently de fine it as the sur gi cal methodof choice.

Key words: kid ney, cyst, treat ment, miniinvasivesur gery

IN TRO DUC TION

Sim ple re nal cysts are the most com mon re nal le sions.They are found in 5% of the com mon pop u la tion.

Rare in chil dren, they in crease with age and reach25-33% in pa tients above 50 years of age. They com prise 65-70% of all ac ci dently found re nal le sions. The be nignre nal cysts are more com mon in males than in fe males(male/fe male ra tio 2:1). They may be sol i tary or mul ti -ple; uni lat eral or bi lat eral1,2,3. The re nal cysts vary in size, but rarely be come so large to be pal pated across the ab -dom i nal wall 4.

With re gard to the dif fer en tial di ag no sis, sim ple re nalcysts should be dif fer en ti ated from the cys tic vari ant ofthe re nal cell car ci noma. The ul tra sound (US) find ings,sup port ing the di ag no sis of a sim ple re nal cyst, in cludethe pres ence of an anechoic round mass, with smooth and clearly dis tin guished wall, fol lowed by a hyperechoicsig nal on the pos te rior wall. If the US data are sus pi ciousor equiv o cal, com puted to mog ra phy (CT) scan should beper formed in ad di tion. The CT cri te ria for a be nign cystin clude: 1) a cyst with strictly dis tin guished bor ders, with a smooth and thin wall; 2) pres ence of a ho mo ge neousliq uid con tent (usu ally with den sity <20 HU, al thoughhigher val ues might be es tab lished in be nign cysts rich in pro tein, or with a hem or rhage within the cyst); 3) the cyst does not en hance the con trast me dium 3, 4.

In 1986 M. Bosniak pub lished a clas si fi ca tion to cat e -go rize the re nal cysts, based on CT find ings, de ter min ing the need for ad di tional di ag nos tic or ther a peu tic pro ce -dures 5. This clas si fi ca tion rap idly gained pop u lar ity andnow a days is used through out the whole world6,7 (Ta ble 1).

.........................................Laparoscopic transperitoneal renal cyst decortication

Al ex an der Hinev, Deyan AnakievskiVarna Med i cal Uni ver sity “St. Ma rina” Uni ver sity Hos pi talVarna, Bul garia

/STRU^NI RAD UDK 616.61-003.4-089.8DOI:10.2298/ACI1401035H

emizer

The ac ci dently found (es pe cially small) asymp tom aticre nal cysts do not re quire sur gi cal treat ment.

The main in di ca tions for sur gi cal treat ment are: pain,hematuria, in fec tion, hy per ten sion or ob struc tion of thekid ney (cat e gory III and IV, ac cord ing to the Bosniakclas si fi ca tion) 8.

The ther a peu tic op tions of the symp tom atic re nal cystsin clude: as pi ra tion with in stil la tion of scle rotic agents;percutaneous marsupialisation; open or lap aro scopic de -cortication or fen es tra tion 1, 8-10.

The tech nique of the lap aro scopic decortication of asim ple re nal cyst was first de scribed by Hulbert et al. in1992, as an al ter na tive to open sur gery11. The lap aro -scopic ap proach may be ei ther transperitoneal or retrope-ritoneal.

The aim of the pres ent study was to re port our ex pe ri -ence with the lap aro scopic transperitoneal treat ment ofsimple re nal cysts, to an a lyze the im me di ate and long-term clin i cal out comes, and to eval u ate the ef fi cacy andsafety of this miniin va sive sur gi cal pro ce dure.

MA TE RIAL AND METH ODS

Be tween 2009 and 2014 a to tal of 48 pa tients withsymp tom atic sim ple re nal cysts were di ag nosed andtreated in our clinic. The di ag no sis was set up by USand/or CT ex am i na tion, used to dis tin guish the even tualcom mu ni ca tion be tween the cyst and the pyelocalycealsys tem of the kid ney (Fig ure 1).

All cases were man aged by transperitoneal lap aro scopiccyst decortication.

SUR GI CAL TECH NIQUE

Af ter in duc tion into gen eral an es the sia, the pa tient re -mained in a su pine po si tion, with a slight (30o) el e va tionof the body on the side of the re nal cyst. A to tal of 4 tro -cars were used: 1 10-mm paraumbilical port for the 30o

cam era; 1 10-mm port 5-7 cm lat er ally, close to the lat -eral bor der of m. rectus abdominis; 1 5-mm midline portlo cated 5-7 cm above the um bi li cus, and 1 5-mm port, lo -cated on the re spec tive midaxillary line.

Af ter ini tial in spec tion of the ab dom i nal cav ity andiden ti fi ca tion of the main an a tom i cal mark ers and othercon com i tant pa thol ogy, lo cal iza tion of the re nal cyst wasdone. In most cases it ap peared im me di ately in the vi sualfield as a blue cu pola, pro trud ing above the sur face of the kid ney (Fig ure 2). There were 2 ap proaches to the cyst:in di rect, with in ci sion of the pos te rior peritoneal layerfol lowed by mo bi li za tion of the bowel me di ally, or di -rect, di rectly to the cyst, with out mo bi li za tion of thebowel, which re mained on site. The dis sec tion was donein an acute and blunt man ner, us ing a grasper andmonopolar scis sors or a har monic scal pel (Fig ure 3).

Af ter mo bi li za tion of the roof of the re nal cyst, the lat -ter was punc tured by an 18-gauge nee dle, and the cyst’scon tent was as pi rated. Af ter the ini tial de com pres sion,the punc ture site was en larged to al low in ser tion of theas pi ra tion pump into the lu men of the cyst. This ma neu -ver was used to en hance the as pi ra tion of the cyst’s con -tent (Fig ure 4).

In case of sus pi cious im ag ing and/or clin i cal signs of ama lig nancy, the as pi rated liq uid was sent for cytopatho-log i cal anal y sis (for con ven tional cy tol ogy and for immu-

36 A. Hinev et al. ACI Vol. LXI

FIGURE 1.PRE OP ER A TIVE CT SCAN, SHOW ING A LARGE

SIM PLE RE NAL CYST ON THE RIGHT.

FIGURE 3. LAP ARO SCOPIC DIS SEC TION OF THE RE NAL CYST.

FIGURE 2. LAP ARO SCOPIC VIEW OF A SIM PLE RE NAL CYST.

nocytochemical ex am i na tion of CA9 – a pow er ful tu mormarker, sup port ing the di ag no sis of re nal cell car ci -noma)12.

Af ter com plete evac u a tion of the cyst’s con tent andme tic u lous in spec tion of the walls to ex clude malignan-cy, the roof of the cyst was ex cised by monopolar scis -sors at 5-mm dis tance from the re nal pa ren chyma (Figure 5). The spec i men was sent for def i nite pathohistologicalex am i na tion. The hemostasis was eas ily done by elec tro-co ag u la tion of the edges of the cyst, with out fulgurationof its ba sis that might af fect the re nal pa ren chyma. Theab dom i nal cav ity was then in spected again and a 16 Frpoly eth yl ene drain was in serted via the lat eral 5-mmtrocar. The op er a tion ended with desuflation and cos -metic clo sure of the ab dom i nal ports.

The de mo graphic data, the perioperative blood loss, the du ra tion of the op er a tive pro ce dure, the length of the hos -pi tal stay and the peri- and post op er a tive com pli ca tionswere an a lyzed.

The fol low-up in cluded clin i cal ex am i na tion and re nalUS, per formed at 3-monthly in ter vals dur ing the first yearand yearly there af ter.

RE SULTS

The de mo graphic data of the pa tients and the ba sic pa -ram e ters, char ac ter iz ing the re nal cysts and the sur gi calmethod ap plied, are ex posed on Ta ble 2.

Pa tient age ranged from 32 to 68 years (mean age 52.4years). 27 (56.2%) of the pa tients were males and 21(43.8%) - fe males.

The lead ing clin i cal symp tom, be ing the main in di ca -tion for the im ple men ta tion of sur gery, was pain in thelum bar area, found in 42 (87.5%) of the pa tients. In 1 pa -tient only (2.1%) there was ob struc tion /hydrocalycosis/,due to com pres sion of the cyst. Hy per ten sion was foundin 2 cases /4.2%/; hematuria – also in 2 cases /4.2%/, anduroinfection with E. coli /105/ - in 1 case /2.1%/.

Most of the cysts - 42 (87.5%) were pe riph eral, and 6(12.5%) – peripelvic; 28 (58.3%) were lo cal ized to the left0 (41.7%) – to the right; and they ranged by size from 5 to 30 cm (mean 9.8 cm). 45 (93.8%) of the cysts were iden ti -fied as cat e gory I, and only 3 (6.2%) - as cat e gory II, ac -cord ing to the Bosniak clas si fi ca tion.

None of the cases re quired con ver sion to open sur gery.There were no peri- and/or post op er a tive com pli ca tions,di rectly re lated to the sur gi cal pro ce dure.

The av er age du ra tion of the lap aro scopic pro ce durewas 55min (range 30 - 95 min), and the av er age periop er a -tive blood loss - 50 mL (range 0 - 90 mL).

“One shot” pre op er a tive an ti bi otic pro phy laxis was ap -plied in all cases. Post op er a tively, analgetics wereneeded dur ing the first 12 – 24 hours only. The ure thralcath e ters were usu ally re moved on the first morn ing af ter the pro ce dure. The mean hos pi tal iza tion pe riod was 4.2days (range 3 - 7 days). All pa tients had neg a tive cy to -log i cal and histological find ings in dic a tive for ma lig -nancy. The fol low-up pe riod ranged from 5 to 52 months(averge-25,4 months)

Ex cel lent ther a peu tic re sults were re ported in 47 cases(97.9%): com plete re lief of the clinical symp toms, cos -metic wound heal ing with fast recov ery of the physicalac tiv ity and the pre vi ous pa tient qual ity of life (Fig ure 6).

The fol low-up US and CT ex am i na tions con firmed thecom plete res to ra tion of the anat omy of the op er ated kid -neys (Fig. 7). There were three re cur rences (6.2%) met in pa tients with mul ti ple cysts, but only one of them re -quired re peated sur gery.

DIS CUS SION

Due to their small di men sions and lack of clin i calsymp toms, the great ma jor ity of the sim ple re nal cysts do not re quire treat ment. Sur gery is in di cated with cyst en -large ment and ap pear ance of clin i cal signs (pain,hematuria, hy per ten sion, re nal ob struc tion, cyst rup ture,

Br. 1 Laparoscopic transperitoneal re nal cyst decortication 37

TABLE 1

THE BOSNIAK CLASSIFICATION OF RENAL CYSTIC DISEASE

Bosniak category CharacteristicsMalignantrisk (%)

Work up

Category I (uncomplicated,simple benign cyst)

Thin wall, without septations, calcifications or rigidcomponents; homogeneous water content (<20 HU);sharp delineation with the renal parenchyma; nocontrast enhancement

<1% No follow up

Category II (minimally complexcyst)

Thin wall (< 1 mm), with fine calcifications and/orseptations; < 3 cm in diameter; no contrastenhancement

<3% No follow up

Category II F (cystic lesion withincreased abnormal findings)

Slightly thick and irregular wall; multiple thinseptum; presence of calcifications or dense lesions; = 3 cm in diameter; no contrast enhancement

5-10%US/CT

follow up

Category III (more complicatedrenal cyst)

Uniform wall thickening/nodularity; multiple thicksepta; thick/irregular calcifications; contrastenhancement

40-60%Surgicalexcision

Category IV (malignant cyst)Large cystic components; irregularmargins/prominent nodules; solid enhancingelements (> 10 HU), independent of septa

>80%Surgicalexcision

re cur rent uroinfections, pro gres sively grow ing intraabdo- minal tu mor mass, etc.) 13,15.

Treat ment of sim ple re nal cysts usu ally fo cuses onsymp tom con trol and on the pre ven tion of ad di tionalcom pli ca tions. It is com monly ac cepted that in terms oflong-term per spec tive open decortication is the most suc -cess ful, al though the most mor bid, ther a peu tic pro ce dure, com pared to the other miniinvasive treat ment meth ods –percutaneous nee dle as pi ra tion (with or with out sclero-ther apy) and lap aro scopic decortication.

Prior to in tro duc tion of the lap aro scopic decortication,the percutaneous nee dle as pi ra tion, with or with out in stil -la tion of scle rotic agents, was the first line of di ag no sisand treat ment. The clin i cal ex pe ri ence ac cu mu lated withtime rap idly showed, how ever, that the as pi ra tion andsclerosation of the re nal cysts was not al ways an ef fec tive method of treat ment11. Be sides, the re cur rence rate af tercyst as pi ra tion and sclerosation is within the range of40-100%, un like the re ported suc cess rate of lap aro scopic decortication that is rang ing from 90 to 100% 1,2,16,17.

There fore, lap aro scopic decortication of sim ple re nalcysts has been re cently es tab lished as a highly ef fec tiveand safe miniinvasive method of treat ment. Most of theau thors, ap ply ing this method, re port a high sat is fac tion

rate (both of the pa tients and their phy si cians); high suc -cess rate; low re cur rence rate and min i mum mor bid ity,closely re lated to the pro ce dure8,13,15,18,19.

38 A. Hinev et al. ACI Vol.LXI

FIGURE 6. VIEW OF THE PA TIENT AT THE FIRST CHECK UP,

FIGURE 7.POST OP ER A TIVE CT SCAN (1 YEAR AF TER LAP ARO -

SCOPIC CYST DECORTICATION), SHOW ING PER FECT

RES TO RA TION OF THE RIGHT KID NEY ANAT OMY.

FIGURE 4. OPEN ING OF THE CYST AND AS PI RA TION OF ITS

CON TENT.

FIGURE 5. PAR TIAL EX CI SION OF THE CYST’S WALL.

The suc cess rate var ies among the dif fer ent se ries, be -cause it is closely de pend ent on a va ri ety of fac tors, suchas: the size and the lo ca tion of the cyst(s), the sur gi caltech nique ap plied, the ex pe ri ence and the skill of the sur -geon etc.

Us ing ex clu sively a transperitoneal ap proach, we achi-eved a ra dio log i cal and symp tom atic suc cess in 97.9% of the cases. In a study, com pris ing 19 con sec u tive pa tients,Tefekli et al.18 re ported a ra dio log i cal suc cess of 88.2%and a symp tom atic suc cess of 89.5%. It is in ter est ing tonote that in all these cases a retroperitoneal ap proach hadbeen used. Shiraishi et al. 15 pub lished a se ries of 37 pati-ents, who un der went lap aro scopic re nal cyst decortica-tion be tween 1993 and 2004. In five of these pa tients(13.5%) the size of the cysts had in creased more than50% of the ini tial di men sions on the very first check upex am i na tion fol low ing the pro ce dure. One of the pos si ble ex pla na tions of this re sult is that the au thors used atransperitoneal ap proach only in case of pe riph eral lo ca -tion of the cysts. In the rest 7 cases, a retroperitoneal ap -proach had been used. Con trary to that, Okeke et al. 20 re -port 100% symp tom atic suc cess in a mean fol low up of17.7 months af ter lap aro scopic re nal cyst decortication.

The transperitoneal ap proach, com pared to the retro-peritoneal one, has cer tain ad van tages: Firstly, the an a -tom i cal mark ers can be iden ti fied much eas ier. Sec ondly,the intraperitoneal space ex ists nat u rally and is muchlarger than the space ar ti fi cially cre ated by the retrope-ritoneal ap proach. All that of fers a much larger work ingspace, a pos si bil ity of in spec tion and ex am i na tion of theother ab dom i nal or gans (liver, in tes tines, etc.), and of di -ag nos ing of other con com i tant dis eases. Thirdly, the abil -ity of the peri to neum to re ab sorb liq uids avail able in theab dom i nal cav ity should not be ne glected. In our view,this is the most sig nif i cant fac tor that ex plains the greatther a peu tic suc cess of the transperitoneal ap proach.

Be side its dis tinct ad van tages, the transperitoneal ap -proach has some po ten tial dis ad van tages, too: it re quiresa sig nif i cant clin i cal ex pe ri ence and bears the risk of in -jury of the ab dom i nal or gans and/or blood ves sels in case of neg li gence 4,12.

Our re sults, how ever, con vinc ingly show that the lap -aro scopic transperitoneal decortication of sim ple re nalcysts is an easy, highly ef fec tive min i mally in va sivemethod that has dis tinct ad van tages over the rest of thetreat ment meth ods (min i mal post op er a tive pain, min i malblood loss, short hos pi tal iza tion, re duced post op er a tivereconvalescence, and an ex cel lent cos metic ef fect). These ad van tages are sig nif i cantly better ex pressed in larger re -nal cysts.

CON CLU SION

The lap aro scopic transperitoneal decortication is aminiin va sive, highly ef fec tive and safe method of treat -ment of symp tom atic sim ple re nal cysts. The symp tom -atic suc cess, ob served im me di ately af ter the pro ce dure,the short pe riod of reconvalescence, the ex cel lent pa tientqual ity of life and the low re cur rence rate clearly de fine it as the sur gi cal method of choice.

Br. 1 Lap aro scopic transperitoneal re nal cyst decortication 39

TABLE 2

MAIN PARAMETERS, CHARACTERIZING THEPATIENTS, THE RENAL CYSTS, AND THE

SURGICAL METHOD APPLIED

Parameters Value

Mean age (range), years 52.4 (32-68)

Gender, n(%)

males 27 (56.2%)

fe males 21 (43.8%)

Main indication for surgery, n(%)

pain 42 (87.5%

hematuria 2 (4.2%

hy per ten sion 2 (4.2%)

in fec tion 1 (2.1%)

ob struc tion 1 (2.1%)

Side n(%)

right 20 (41.7%)

left 28 (58.3%)

Lo ca tion, n(%)

pe riph eral 42 (87.5%)

peripelvic 6 (12.5%)

Bosniak category, n(%)

cat e gory I 45 (93.8%)

cat e gory II 3 (6.2%)

Mean di am e ter of the cyst (range),cm 9.8 (5-30)

Mean vol ume of the as pi rated fluid (range), mL 400 (100-1700)

Mean op er a tive time (range), min 55( 30-95)

Mean blood loss (range), mL 50 (0-90)

Mean hospitalization period(range), days 4.2 (3-7)

Mean follow up period (range),mohtns 25.4 (5-52)

Therapeutic success, n(%) 47 (97.9%)

Recurrences, n(%) 3 (6.2%)

SUM MARY

Cilj studije je da prikaže naša iskustva u laparoskop-skom transperitonealnom tretmanu jednostavnih bubrež-nih cisti kao i da analizira neposredne, dugoro~ène rezul-tate i efikasnost ove minimalno invazivne hirurške proce- dure. Metode: U pe riod od 2009. do 2014. godine dijag-nostikovano je i tretirano 48 bolesnika sa simptomatskimjednostavnim renalnim cistama. Dijagnoza je postavljanaultrazvukom (UZ) i/ili kompijuterizovanom tomografi-jom (CT). Kod svih bolesnika je uradjena transperitone-alna laparoskopska dekortikacija ciste. Demografski po-daci, perioperativni gubitak krvi, dužina trajanja proce-dure, dužina hospitalizacije kao i peri i postoperativnekomplikacije su pra}ene. Pra}enje je podrazumevalo ul -tra-zvuk na svaka tri meseca prve godine a potom jednom godišnje. Rezultati: Starost bolesnika bila je od 32 do 68godina (srednja vrednost 52,4). Muškaraca je bilo 27(56,2%) dok je `ena bilo 42 (43,8%). U 42 slu~èaja cistaje bila periferno (87,5%), 6 slu~èajeva (12,5%) peripelvi~- èno. U 28 slu~ajeva (53,8%) cista je bila lokalizovano levo dok je 20 (41,7%) bila lokalizovana desno. Veliè~ina cistise kretala od 5 do 30cm (SV 9,8cm). U 45 (93,8%) slu~èa- jeva ciste su kategorisane kao Bosniak I dok je 3 (6,2%)imalo kategorizaciju Bosniak II. Konverzia nije bilo kaoni peri i postoperativnih komplikacija. Srednja vrednosttrajanja operacije bila je 55 minuta i prose~èan gubitak kr- vi iznosio je 50 ml. Kod svih bolesnika citološki i his-tološki isklju~èeno je postojanje maligniteta. Pe riod pra-}enja kretao se od 5 do 52 meseca (SV 25,4 meseca).Odli~an terapeutski rezultat sa kompletnim odsustvomsimptoma, brzim oporavkom i dobrim kvalitetom `ivotazabele`en je kod 47 (97,9%) bolesnika. Bilo je tri (6,2%)rekurentnih cisti kod bolesnika sa multiplim cistama odkojih je samo jedna reoperisana. Zaklju~èak: Laparosko-pska transperitonealna dekortikacija je minimalno inva-zivna, visoko efektivna i bezbedna procedura u tretmanurenalnih cisti. Trenutno oslobadjanje simptomatologije,kratak pe riod rekonvalescence i odli~èan kvalitet `ivotanakon operacije definišu je kao metodu izbora u tretmanu nekomplikovanih renalnih cisti

Kljuè~ne re~èi: bubreg, cista, tretmanminimalno-invazivna procedura

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