Laparoscopic Decortication of Simple Renal Cyst with Omental Wadding Technique: Single-Center Experience

Abstract

Objective:

What is the impact of the omental wadding technique on decreasing the incidence of recurrence after laparoscopic decortication of the symptomatic simple renal cyst? This is the question we are trying to answer through this study.

Patients and Methods:

This is a cohort study of 14 consecutive patients who underwent transperitoneal laparoscopic decortication of a symptomatic simple renal cyst with the omental wadding technique between November 2007 and November 2011. The indication for surgery was for relief of pain in all cases. Pain was assessed preoperatively and at 1 month and every 6 months postoperatively using a pain numerical rating scale. Only simple cysts (Bosniak I and II) more than 10 cm in their greatest dimension were included in this study. Patients with complicated cysts (Bosniak III and IV) and those with cysts less than 10 cm in their greatest dimension were excluded from this study. Patients were 7 men and 7 women with a mean age of 47 years (range, 35–63 years), and the mean body mass index was 27 kg/m². Laparoscopic decortication was the primary treatment in 11 cases and the secondary treatment in 3 cases after sclerotherapy. We used the omental wadding technique to try to fill the cavity after decortication to decrease the incidence of recurrence with simple laparoscopic decortication reported in other series. We reviewed the preoperative and postoperative data.

Results:

The operation was successfully completed laparoscopically in all cases with a mean operative time of 97 minutes without major perioperative complications. Hospital stay was 2.4 days (range, 2–4 days). All cases improved significantly after operation in a mean follow-up of 1.5 years. Using this technique, we did not have any recurrence after surgery.

Conclusions:

Laparoscopic decortication with omental wadding is helpful to decrease the incidence of simple renal cyst recurrence after laparoscopic decortication.

Introduction

It is estimated that the incidence of renal cysts is 20% at 40 years of age and 33% at 60 years in the general population.¹ Most renal cysts are asymptomatic, and the diagnosis is usually incidental during abdominal ultrasonography. Up to 5%–10% of renal cysts are symptomatic. The main presentation is flank pain, but occasionally patients may present with hematuria, hypertension, or urinary tract infection. ^2–4

The ideal primary management is sclerotherapy, especially for relatively small simple renal cysts (less than 10 cm in their greatest dimension).⁵ It is a minimally invasive and safe procedure, and it is frequently performed to treat these patients. However, the recurrence rate after simple aspiration alone is 41%–78%. The recurrence rate is around 43% after a single session of sclerotherapy and is lowered to 5% after repeated sessions of sclerotherapy.^6–8

Since the introduction of laparoscopy to urologic surgery in the 1990s, laparoscopic decortication of simple renal cysts has been reported to be an excellent modality of management as it is effective and it can duplicate techniques of open surgery. This is together with the generic advantages of laparoscopy: less invasive, less morbidity, less pain, less analgesic use, short convalescence, and rapid return to work.⁹ However, the incidence of recurrence after laparoscopic decortication only is still high (19%), which is frustrating to both the patient and the urologist.¹⁰ In an attempt to prevent recurrences, different techniques have been described: for example, fulguration of the cyst base, marsupialization, wadding with surgical bolsters, and omental wadding of the cyst.¹¹

In this study we retrospectively assessed the efficacy of laparoscopic decortication with the omental wadding technique.

Patients and Methods

In this cohort study, we evaluated the records of 14 consecutive patients with simple renal cysts admitted to the Urology Department, Farwaniya Hospital, Kuwait, between November 2007 and November 2011. Only simple cysts (Bosniak I and II) more than 10 cm in their greatest dimension were included in this study. Patients with complicated cysts (Bosniak III and IV) and patients with cysts less than 10 cm in their greatest dimension were excluded from this study. We used the omental wadding technique in all cases, trying to decrease the incidence of recurrence encountered with simple laparoscopic decortication reported in other series.

Pain was assessed using a pain numerical rating scale preoperatively and postoperatively after 1 month and every 6 months. Abdominal ultrasonography and computed tomography with contrast were performed for all cases preoperatively to assess type of cyst and to rule out any connection to the pelvicalyceal system.

Ultrasonography was repeated at 1 month and every 6 months postoperatively for 2 years. The mean follow-up was 18 months (range, 6–33 months). Computed tomography was repeated postoperatively if ultrasonography suggested the possibility of recurrence.

Technique

Under general anesthesia, patients were positioned in the lateral position. Through a transperitoneal access, a longitudinal incision was made in the posterior peritoneum on the line of Toldt followed by medialization of ascending or descending colon. Gerota's fascia was then dissected to expose the kidney. Aspiration of the cyst was done using an aspiration needle inserted through the skin under laparoscopic guidance. Excision of the cyst wall (unroofing) was then done. Cauterization of the edges and wadding the cavity with omentum were performed to decrease the possibility of recurrence. Intracorporeal sutures and clipping were used to fix the omentum to the cyst edges. A drain was left for 1 day only. Removal of ports and closure of port sites were performed.

Results

Our study included 7 men and 7 women. The estimated mean age of patients was 47 years (range, 35–63 years), and the mean body mass index was 27 kg/m². The demographics and operative data are summarized in Table 1.

Table 1.

Demographics and Operative Data

Parameter	Value
Mean (range) age (years)	47 (35–63)
Gender (male:female)	7:7
Mean (range) cyst size (largest dimension) (cm)	14.5 (11–19)
Approach	All transperitoneal
Mean (range) operative duration (minutes)	95 (60–135)
Mean (range) blood loss (mL)	50 (30–80)
Mean (range) hospital stay (days)	2.4 (2–4 days)
Recurrence	0

All cases presented with pain. The estimated mean largest cyst dimension measured by computed tomography was 14.5 cm (range, 11–19 cm). Twelve cases had a single cortical cyst, and 2 had more than one cyst. There were no parapelvic cysts in our series. Laparoscopic decortication was the primary treatment in 11 cases and the secondary treatment in 3 cases after sclerotherapy.

The operation was successfully completed laparoscopically in all cases with no conversion to open surgery. There were no major perioperative complications. Only 1 patient developed ileus postoperatively and stayed in the hospital for 4 days; this was due to some colonic adhesions that required more dissection. Hospital stay was 2.4 days (range, 2–4 days). The mean blood loss was 50 mL (range, 30–80 mL). The mean operative time was 95 minutes (range, 60–135 minutes).

We had no recurrence in our study, and all cases significantly improved after operation with a mean follow-up of 1.5 years. The mean pain numerical rating score was 5.5 preoperatively and decreased to 0.5 after 1 month postoperatively.

Discussion

The ideal management of a symptomatic simple renal cyst should be less invasive and effective with a low recurrence rate. Aspiration only or aspiration sclerotherapy is less invasive; however, the recurrence rate is relatively high.^6,7 Open surgery offers a high success rate; however, it is an invasive procedure with the co-morbidity of flank incision. Laparoscopic decortication offers effective treatment with a high success rate comparable to that of open surgery with the advantage of being a less invasive modality of management.^9,10

In spite of the advancement of different laparoscopic techniques, the reported recurrence rate is still up to 19%, regardless the technique used.¹⁰ Recurrence after laparoscopic decortication could be explained by incomplete resection of the cyst wall. The residual secreting cyst wall can become adherent to surrounding tissues with development of a new cyst.^11,12 To prevent recurrences, different techniques have been reported: for example, cyst decortication with fulguration of the cyst base, marsupialization, resection with surgicel bolsters positioned into the base of the cyst, and omental wadding of the cyst.^13–16

The wadding technique can be achieved through a retroperitoneal approach using perirenal fat or through a transperitoneal approach using omentum or perirenal fat.^2,15 The transperitoneal approach with the omental wadding technique has the advantage of larger working space and availability of the omentum to wad the big cavities remaining after decortication of huge cysts that may be difficult to be filled with perirenal fat.

Our main concern in this study was to decrease the significant incidence of recurrence that happens with simple laparoscopic decortication. We started by ensuring complete excision of the cyst wall and then wadded the floor of the cyst with omentum and fixed it with intracorporeal sutures and clips. We did not have any recurrence with this technique. This high success rate agrees with other series reporting a lower recurrence rate with this technique.²

Conclusions

The omental wadding technique is helpful to decrease the incidence of cyst recurrence after laparoscopic decortication. However, it is better to evaluate this technique with further prospective studies that are matched with a control group.

Footnotes

Disclosure Statement

No competing financial interests exist.

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