Retrospective Evaluation of the Clinical Values of Minimally Invasive Marsupialization of Symptomatic Giant Renal Cysts

Abstract

Background:

To evaluate the indication and benefit of minimally invasive laparoscopic marsupialization (MIS) of symptomatic giant renal cysts.

Materials and Methods:

Sixty-four consecutive patients who underwent MIS for large renal cysts (Bosniak I; 4 × 5–16 × 12 cm) by one surgeon were included in the study. Presenting symptoms were renal pain (100%), associated with hypertension (28%), renal dysfunction (4.7%), hematuria (4.7%), ureteropelvic junction obstruction (UPJO) (7.8%), ipsilateral urolithiasis (4.7%), polycystic kidney (6.3%), adrenal cyst (1.6%), and retroperitoneal cysts (1.6%). Seven patients with peripelvic cysts and previous retroperitoneal operations were treated by a laparoscopic approach; all other patients underwent retroperitoneoscopic marsupialization. Single-port retroperitoneoscopy was performed in 4 patients. Follow-up included clinical examination, abdominal ultrasound, and computed tomography scan. Postoperative radiologic success was defined as a minimum of 50% in size reduction and no recurrence.

Results:

Mean patients' age was 46 (21–65) years. All procedures were successfully completed without conversion or revision. Mean operative time was 55 (40–85) minutes with a mean hospital stay of 3 days. All patients underwent uneventful postoperative recovery. Observed minor complications (transitory fever/pain) were found in 4 patients during the first postoperative month. Median follow-up was 12 months (10 months–2 years). About 98.5% of patients reported of no relevant postoperative pain. A relief from UPJO and hematuria was achieved in 100% of patients. Ten patients with known hypertensive disease (55.6%) had a significant reduction of mean blood pressure resulting in a reduction of antihypertensive medication. Ureterorenoscopic stone extractions were performed successfully afterward. No cyst recurrences were detected during the follow-up period.

Conclusion:

Treatment indications for symptomatic renal cysts could include not only symptoms but also associated diseases like UPJO and hypertension. Retroperitoneoscopic MIS may be curative for these cyst-associated pathologies. The feasibility, safety and efficacy of these techniques could be demonstrated.

Background

With an estimated prevalence of up to 12% in adults, simple renal cysts (Bosniak I) are considered a common finding in the general population.^1,2 Being mostly asymptomatic, they are usually diagnosed incidentally and their incidence increases with the widespread use of imaging diagnostic measures.²

Therapy is only indicated if patients are symptomatic and present with pain or compression of adjacent organs or the collecting system. As there is no effective medical treatment, a more invasive therapeutic approach is needed in most cases.

The percutaneous cyst aspiration (with or without instillation of sclerotherapeutic agents) and transperitoneal cyst decortication have been the most common recommended managements in literature.^3–7

Considering the reported high recurrence rates after cyst aspiration, minimally invasive laparoscopic and/or retroperitoneoscopic approaches have emerged to become the gold standard of the treatment of symptomatic renal cysts.^3,8–10

Laparoscopic or retroperitoneoscopic marsupialization of peripelvic cysts are being performed safely and efficiently in experienced centers. Nevertheless, giant renal cysts remain a technically challenging procedure for the practicing surgeons.^11–13

The surgical approach for this condition as well as the indications and benefits from surgery remain controversial. This study evaluates the feasibility and postoperative results of minimally invasive marsupialization in 64 consecutive patients with giant Bosniak I renal cysts, who presented with various symptoms and accompanying manifestations.

Benefits and outcomes of this surgical technique were evaluated with appropriate follow-up period to determine the possible indications and clinical value of these procedures.

Materials and Methods

Patient collective

In this study, data of 64 consecutive patients who underwent laparoscopic marsupialization of symptomatic giant renal cysts were evaluated. All patients provided consent for surgery and postoperative follow-up. Diagnosis of large renal cysts and standardized visualization of their parameter and relation to kidney and surrounding organs were performed through preoperative imaging with abdominal computed tomography (CT) scan and ultrasound. Renal scintigraphy and retrograde pyelography were performed when ureteropelvic junction obstruction (UPJO) was suspected to verify the need for a possible surgical intervention.

All patients were scheduled for retroperitoneoscopic marsupialization of their renal cysts after adequate counseling and written informed consent. Surgical procedures were performed under general anesthesia by one experienced surgeon (W.Y.K.).

Surgical procedure

Retroperitoneoscopic approach was used for all cases except 7 patients, who underwent laparoscopic approach owing to peripelvic cysts and previous retroperitoneal operations. Single-port retroperitoneoscopy was used in 4 patients. All procedures were executed with three ports only (12 mm [camera], two 5 mm). Patients were positioned in a full flank position. The operative approach was performed as previously described by our working group.¹⁴ Marsupialization of symptomatic giant renal cysts was performed as follows: The retroperitoneum was bluntly entered through a 1 cm skin incision at the tip of the 12th rib. The retroperitoneal space was adequately enlarged using a self-made balloon from a double middle finger of “size 8” surgical glove filled with 700 mL of saline. This incision was used for the camera port. A 30° telescope optic was used.

In addition, two 5 mm trocars were inserted under vision: the first trocar was positioned 2 cm anterior to the anterior–superior iliac spine and the second trocar was positioned caudal to the middle of a line between the camera and the anterior trocar. Adequate peritoneal pealing from the abdominal wall was performed to provide a satisfactory working space. After opening the Gerota fascia and identification and complete preparation of the renal cysts from para-renal fat, the cysts were decorticated with cautious preparation. Finally, a sufficient window in the posterior peritoneum for complete and efficient drainage was created. Para-pelvic cysts were surgically removed through a trans-mesenterial approach (Supplementary Video S1).

Follow-up

Follow-up was based on the evaluation of medical records and telephone surveys of the patients and their medical physicians. Clinical examination and abdominal ultrasound were routinely performed 3 months postoperatively. In addition, CT scans were performed if indicated. Radiologic success was defined as a reduction in cyst size of at least 50% and no cyst recurrence during the follow-up period. The improvement of a concomitant hypertension was based on the overall decrease of mean blood pressure and/or reduction of the antihypertensive medication as stated by the patients' medical physicians.

Results

Mean patient age was 56 (24–76) years. Presenting symptoms were renal pain (64/64; 100%), associated with hypertension (18/64; 28%), slight serum creatinine elevation (3/64; 4.7%), microscopic hematuria (3/64; 4.7%), classical picture of UPJO owing to peripelvic cysts (5/64; 7.8%), and ipsilateral stone disease (3/64; 4.7%). Polycystic kidney was present in 4 of 64 cases (6.3%), adrenal cyst and retroperitoneal cyst in 1 of 64 cases (1.6%). The preoperative demographic, laboratory, and clinical patient characteristics are summarized in Table 1.

Table 1.

Preoperative Demographic, Laboratory, and Radiologic Data of 64 Patients with Giant Renal Cysts, Who Underwent Retroperitoneoscopic Renal Cyst Marsupialization

Parameter	Patients numbers/total	%
Gender: male/female	49/15	76.6/23.4
Patient age (mean) years	24–76 (56.2)
Affected kidney side right/left	29/35	45.3/54.7
Serum creatinine (mean)(mg/dL)	0.7–3.2 (1.1)
Associated stone disease	3/64	0.5
Hydronephrosis (grade II–III)	5/64	7.8
Polycystic kidney	4/64	6.3
Mean systolic blood pressure (mmHg)	123
Hypertension	18/64	28
Diabetes mellitus	9/64	9.4
Hypercholesterolemia	25/64	39

The radiographic findings of the included patients with large renal cysts are given in Table 2. The cysts were located in different parts of the kidney, which indicates that the concomitant symptoms, except for UPJO, do not depend on a specific location in the renal parenchyma. Five patients (7.8%) showed a peripelvic cyst with compression of the pelvicaliceal system simulating UPJO with intermittent flank pain. Two patients had multiple cystic findings, for example, upper and lower kidney pole, which were diagnosed and treated in the same procedure.

Table 2.

Radiologic Characteristics of Giant Renal Cysts in 64 Patients Exposed to Retroperitoneoscopic Renal Cyst Marsupialization

Parameter	Patients numbers/total	%
Affected side: right/left	29/35	45.3/54.7
Size (mean) cm	4 × 5–16 × 12 (8 × 10)
Position in the kidney
Upper pole	19/64	29.7
Lower pole	17/64	26.6
Middle parenchyma	21/64	32.8
Para-pelvic	5/64	7.8
Polycystic kidney	4/64	6.3

Note that the higher sum of the cystic findings than patients' number is related to multiple cysts, for example, upper and lower kidney pole locations, which were diagnosed in the same patient.

All procedures were successfully completed without conversion to an open approach or revision. Mean operative time was 55 (40–85) minutes with a mean hospital stay of 3 (2–11) days. All patients underwent uneventful postoperative recovery. According to the Clavien–Dindo classification, no major complications were observed perioperatively. Minor complications (transitory fever/pain), considered as grade I complications, were found in 4 patients during the first postoperative month (Table 3).

Table 3.

Operative and Outcome Results in 64 Patients Who Underwent Retroperitoneoscopic Giant Renal Cyst Marsupialization

Parameter	Patients numbers/total
Operative time (median) in minutes	40–85 (55)
Hospital stay (mean) in days	2–11 (3)
Postoperative complications (first month)
Major	0/64 (0%)
Minor (fever, postoperative pains)	4/64 (6.3%)
Time to full convalescence	3 weeks
Outcomes, n (%)
Radiological success	64/64 (100%)
Clinical success
Pain	64/64 (100%)
Hematuria	64/64 (100%)
Hypertension (improvement)	10/18 (55.6%)
Hydronephrosis	5/5 (100%)
Follow-up	10 months–2 years

Note that the improvement of the hypertension control was based on the overall decrease of mean blood pressure and/or reduction of the acquired antihypertensive medicaments.

Mean follow-up was 12 months (minimum 10 months to maximum 24 months). The evaluation of the patients revealed a pain recovery in 98.5% of cases. Follow-up renal scintigraphy and abdominal sonography revealed a complete relief from UPJO resulting in a stable ipsilateral renal function without obstructive elements. Regular urine analysis showed complete disappearance of microscopic hematuria in 100% of affected cases. Among the 18 patients with preoperative hypertension, the mean (range) greatest dimension of the cyst was 9.4 (5–16) cm, whereas the baseline systolic blood pressure was 138 (120–175) mmHg (Table 4). There was a tendency to lower blood pressure values on evaluation on the third postoperative day, however without statistical significance (P = .130 and P = .075 for systolic and diastolic findings, respectively).

Table 4.

Comparison Between Preoperative Blood Pressure Findings with the Third Day Postoperative Measurements in 18 Hypertensive Patients Who Underwent Laparoscopic Kidney Cyst Marsupialization

Blood pressure	Median	Mean	Min.–max.
Preoperative systolic	135	138	120–175
Preoperative diastolic	77.5	79	60–105
Third day postoperative systolic	130	132	110–170
Third day postoperative diastolic	75	75	60–90

There was no significant relationship between cyst size and systolic blood pressure (P = .99). Ten of 18 patients with prior hypertension (55.6%) had a significant reduction of the mean blood pressure (20–28 mmHg lower systolic) in postoperative follow-up. In addition, it was evaluated by their medical physicians that hypertension was easier to control with relevant dose reduction of the antihypertensive drugs.

No significant changes were noticed in laboratory examinations (i.e., cell counts, C-reactive protein, and serum creatinine) postoperatively. Ureterorenoscopic extractions of renal stones were performed successfully and all patients who had to undergo such a procedure were stone free afterward. No cyst recurrences were detected in any case during follow-up, with a maximum time of 24 months. Results of postoperative outcomes are given in Table 3.

Discussion

Laparoscopic and retroperitoneoscopic decortication and marsupialization of renal cysts represent a well-established operative technique in the treatment of symptomatic renal cysts providing very satisfactory long-term results.¹⁵ The indications and adequate time to treat renal cysts are controversially discussed.^15,16 Giant renal cysts are usually scheduled for treatment because of persisting pain and less frequently because of obstruction of the ureteropelvic junction.

This retrospective study shows the feasibility and efficacy of minimally invasive marsupialization of giant renal cysts to relieve pain as well as associated symptoms and clinical conditions in 64 consecutive patients.

There are important characteristics of this study in comparison with published trials. Concerning postoperative pain relief, current findings are in line with previously published results of laparoscopic and retroperitoneoscopic decortication of renal cysts. In the presented patient collective, immediate pain relief could be observed in 98.5%. Chen et al. analyzed 36 patients with symptomatic peripelvic cysts (mean size 7.9 cm) who underwent retroperitoneoscopic decortication and reported pain relief in 97.2%.¹² Moreover, Thwaini et al. reported a long-term symptom-free rate of 77% after a median follow-up of 5 years.¹⁶ Recently, Shao et al. reported a 100% pain relief rate in 31 patients with symptomatic peripelvic cysts who underwent percutaneous intrarenal marsupialization after a median follow-up of 12 months.¹⁷

An important characteristic of this study is that all included patients had symptomatic, giant renal cysts in different parenchymal localizations. This significant proportion of peripheral renal cysts was further analyzed. It needs to be stated that most of the current literature on surgical managements of giant renal cysts (smaller as current collective) are based on patients who presented with symptomatic peripelvic cysts.^12,15–17 In conclusion, this study is able to suggest a widening of indication for this surgical procedure and to demonstrate the outcomes and benefits for these patients that can be expected.

There are some reports documenting the relationship between simple renal cysts and increased arterial blood pressure.^18,19 Recently, Hong et al. analyzed a large patient collective of 29,666 cases and found a significant correlation between presence of simple renal cysts and hypertension. Peripheral location, size (>4 cm), and multiple cysts were classified as important etiological characteristics.²⁰

Moreover, Kim et al. screened 3,249 patients and reported a positive correlation of presence of simple renal cysts and incidence of hypertension.²¹ Cyst size, number, and peripheral localization were discussed as possible contributing factors in the development of hypertension.^19,22 Based on these findings, it seems quite sensible that removal of renal cysts might lead to beneficial effects concerning blood pressure control. In our patient collective, preoperative hypertension was detectable in 18 of 64 cases (28%). During the postoperative follow-up period, mean blood pressure decreased significantly in 55% of these patients, resulting in reduction of the needed antihypertensive medication. The absence of a relation between cyst size and the incidence of hypertension may be owing to the homogenous patient collective including only giant cysts.

Another important finding of the evaluated patient collective was an association with ipsilateral nephrolithiasis (4.7%), hematuria (4.7%), polycystic kidney disease (6.3%), adrenal cyst (1.6%), and retroperitoneal cyst (1.6%). To our knowledge, there is no existing study regarding possible associations between these conditions and large renal cysts. However, there are some publications addressing nephrolithiasis in autosomal dominant polycystic kidney disease causing a significant impairment in urine drainage.²³ This suggests that giant renal cysts might be associated with ipsilateral stone disease. Ureteroscopic stone removal was a feasible treatment option in this study. During follow-up period, there were no recurrences, especially no patient developed nephrolithiasis or hematuria. The safety of this minimally invasive approach was reported in various previous publications.^9,12,16,24

In the current series, the operative time was slightly shorter than previously reported, whereas hospital stay and perioperative blood loss were comparable. There were no conversions to open surgery and no revisions or recurrences that need to be reported.

In addition, there were no major complications according to the Clavien–Dindo classification. This suggests that the large sizes of the cysts may be challenging but does not increase the risk of this surgical approach. Current results support a widening of the indication for the treatment of giant cysts. It reports the safety and efficacy and good outcomes of minimally invasive marsupialization of large renal cysts as therapy of choice.

Besides the homogenous patient collective with only giant cysts, possible study limitations may include all inherited criteria of a retrospective study and the limited number of patients, still supporting the conclusions of our study, especially owing to the very homogenous patient cohort.

Conclusions

The results of this study indicate that minimally invasive marsupialization of giant renal cysts is a feasible, safe, and efficient therapeutic tool not only in terms of pain relief, but also in the treatment of various associated diseases and symptoms such as UPJO, hypertension, hematuria, and urolithiasis. The outcomes of this study add important knowledge concerning the indications and the use of this surgical approach in the treatment of symptomatic giant renal cysts.

Ethical Approval and Consent to Participate

For the retrospective evaluation of our data, there was no required special consent in our institution. All patients have given consent for the operative procedures.

Authors' Contributions

W.Y.K. idea of the article, wrote and revised article, M.G. analyzed and interpreted data, A.S. revised article, S.A. data collection and preparation, S.V. data collection, interpretation, article revisions, C.G. supervision and article revisions. All authors read and approved the final article.

Footnotes

Disclosure Statement

No competing financial interests exist.

Funding Information

No funding was received for this article.

Supplementary Material

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