Comparison of Laparoscopic and Open Surgery in the Treatment of Renal Hydatid Cysts

Abstract

Background:

To compare the efficacy, safety, and long-term results of laparoscopic and open approaches in patients undergoing surgery for renal hydatid cyst.

Materials and Methods:

The files of 36 patients who were surgically treated in our clinic and with diagnosis of renal cyst hydatid confirmed pathologically were reviewed. According to the surgical technique applied, the patients were divided into two groups as open (group 1) or laparoscopic (group 2) partial pericystectomy. Oral albendazole was given 10 mg/kg/day (in two divided doses) for 4 weeks preoperatively and for three cycles of 4 weeks at 1-week intervals after surgery in all patients. Demographic characteristics, laboratory and imaging findings, operation times, hospitalization times, complications, intraoperative bleeding amounts, and recurrence rates were statistically compared in both groups.

Results:

Open partial pericystectomy was performed in 21 patients in group 1, and laparoscopic transperitoneal partial pericystectomy was performed in 15 patients in group 2. Operation time and intraoperative bleeding amount in group 1 and group 2 were 119.6 ± 17.1/116.1 ± 17.6 minutes and 125.7 ± 27.8/113.9 ± 19.2 mL, respectively. There was no statistically significant difference between these values (P = .557, P = .167, respectively). Hospitalization duration of both groups was 5.9 ± 1.4/3.6 ± 0.7 days, respectively. Hospitalization duration in group 2 was statistically significantly shorter (P < .001). No recurrence occurred during postoperative follow-up in either group.

Conclusions:

In the treatment of renal hydatid cysts, laparoscopy, which is a minimally invasive approach, can be technically applied with the same principles as open surgery and has a similar efficacy and safety profile for short- and long-term results.

Introduction

Renal hydatid cyst is a chronic, complex benign parasitic disease caused by the larvae of the cestode Echinococcus granulosus. It is endemic and a serious health problem in sheep-breeding countries, especially in the Mediterranean region, Africa, and Latin America.¹ Clinically, it may present as a wide spectrum that can cause various complications from asymptomatic form to fatal disease.² Although hydatid cyst is most commonly found in the liver (60%–70%) and lungs (20%–30%), it can be seen in many locations. One of the rarely diagnosed places is the kidneys. In general, publications report that isolated kidney involvement accounts for 1%–4% of all cases.^1,3,4

Clinical treatment of hydatid cyst is difficult, and when the literature is reviewed, four methods stand out: surgery, pharmacological, percutaneous treatments, and follow-up for inactive cysts. Although there is still no consensus on the ideal treatment to be used for cystic echinococcosis (CE), surgery continues to be the mainstay of treatment today.^5–14

Although open surgery is preferred for the treatment of renal hydatid cysts, laparoscopic approaches have also been reported in the past decade. To our knowledge, there is no study comparing laparoscopic and open surgery for the treatment of renal CE. In this study, we aimed at comparing the efficacy, safety, and long-term results of laparoscopic and open approaches in patients undergoing surgery for renal hydatid disease in our clinic in the past 20 years.

Materials and Methods

After approval of the ethics committee (2021/1231), the computer records and files of 36 patients who were surgically treated in our clinic between January 2000 and January 2020 with diagnosis of renal cyst hydatid confirmed pathologically were reviewed. Demographic characteristics, symptoms, previous hydatid cyst surgery, and animal contact histories of the patients were evaluated. Ultrasonography (USG) and/or computed tomography (CT) were used as imaging methods in the diagnosis of the patients, and also indirect hemagglutination (IHA) was used as a serological test. Morphological types of cysts were determined according to the World Health Organization Informal Working Group on Echinococcosis (WHO/IWGE) ultrasonographic classification.^15,16

Patients were operated with sterile urine cultures after routine anesthesia examinations. According to the surgical technique applied, the patients were divided into two groups as open (group 1) or laparoscopic (group 2) partial pericystectomy. The decision regarding which type of surgery was applied to the patients was determined as a result of patient and doctor interviews. Oral albendazole was given at 10 mg/kg/day (in two divided doses) for 4 weeks preoperatively and for three cycles of 4 weeks at 1-week intervals after surgery in all patients.

Surgical technique

Open surgery

The retroperitoneal area was entered with a lumbar incision made in 90° flank position under general anesthesia. Gerota's fascia was opened; the cyst was dissected and isolated with gas pads soaked in 10% povidone iodine solution to prevent contamination. After the cyst fluid was aspirated with a needle, 30% hypertonic NaCl solution was injected into the cyst and left for 10 minutes. Then, the cyst was opened and the germinative membrane and daughter cysts were removed. Partial pericystectomy was performed after the cyst wall was unroofed. Sutures were placed in the pericyst margin when necessary to provide hemostasis. Then, the cyst cavity and retroperitoneal area were irrigated with 30% NaCl solution. The surgery was completed by inserting a drain.

Laparoscopic surgery

Surgery was performed transperitoneally under general anesthesia in the 45° lateral decubitus position. The Veress needle was inserted through the supraumblical region, and the working area was obtained by creating 12 mmHg pneumoperitoneum with carbon dioxide gas insufflation. One 10 mm port for a 30° telescope, one 10 mm and two 5 mm ports were emplaced for instruments. The kidney and cyst were localized and dissected from the surrounding Gerota's fascia. Gas pads soaked with 10% povidone iodine solution were placed surrounding the hydatid cyst to prevent contamination.

The liquid content of the cyst was aspirated with an aspiration needle, and the cyst was filled with 30% NaCl solution and left for 10 minutes. Afterward, the perforation was enlarged, the germinative membrane was dissected from the cyst wall, and it was removed with a grasper and placed in the endobag. After checking the cyst cavity with direct vision and re-irrigating with 30% NaCl, the cyst was unroofed by using a vessel sealing system (LigaSure Vessel Sealing System; Valleylab, Boulder, CO, United Kingdom). Subsequently, partial pericystectomy was performed with an ultrasonic dissector (Ethicon Endo-Surgery, Inc., Cincinnati, OH). The operation was terminated by inserting a drain in the cyst cavity.

Postoperative follow-up

During the postoperative period when albendazole was administered, the liver function tests (AST, ALT) of the patients were checked once a week for the first month, and every 2 weeks thereafter. In the postoperative period, abdominal USG or CT was applied in the sixth month to investigate the presence of recurrence. Later, patients were followed up annually. Recurrence was defined as the emergence of new active cysts after definitive treatment, including the reappearance with continuous growth of viable cysts in one area of a previously treated cyst or the emergence of new distant disease. The demographic characteristics, laboratory and imaging findings, duration of surgery, length of stay, early and late complications according to Clavien's-Dindo classification,¹⁷ intraoperative bleeding amounts, and recurrence rates were statistically compared in both groups.

Statistical analysis

Descriptive statistics for data are given as mean, standard deviation, median, minimum-maximum, frequency, and percentage. Pearson chi-square or Fisher's exact test were performed for categorical variables. Normality assumptions were checked with the Shapiro–Wilk test. The differences between the two groups were evaluated by using the Student's t-test for normally distributed data or Mann–Whitney U test for non-normally distributed data. Statistical analysis was performed by using IBM SPSS Statistics for Windows version 22.0 (IBM Corp., Armonk, NY). P < .05 was considered statistically significant.

Results

Thirty-six patients treated surgically in our clinic and pathologically diagnosed with renal hydatid cyst were divided into two groups as open (group 1) and laparoscopic (group 2) according to the type of surgery performed. Open partial pericystectomy was performed in 21 patients in group 1, and laparoscopic transperitoneal partial pericystectomy was performed in 15 patients in group 2. All of the patients had no concurrent hydatid cysts in the liver or any other organ, and the renal hydatid cysts of the patients were isolated and solitary. They were primary patients with no previous history of hydatid cyst surgery. The most common symptom in patients was lumbar pain with a rate of 53%. The differential diagnosis of cyst complicated with hydatid cyst could not be made completely with preoperative radiological and laboratory tests in 2 patients in group 1 and 1 patient in group 2. However, our preoperative and peroperative approach was the same as for other patients, since these patients lived in rural areas, and they had animal contact and family history. The demographic data for the patients, morphological types according to the WHO/IWGE classification, cyst sizes, renal locations, and clinical characteristics are shown in Table 1.

Table 1.

Preoperative Clinical and Demographic Characteristics of Patients According to Surgical Approaches

	Group 1 (open), n = 21	Group 2 (laparoscopy), n = 15	P
Age	44.0 ± 13.0	42.4 ± 12.7	.728^a
Gender, n (%)
Male	13 (62)	8 (53)	.607^b
Female	8 (38)	7 (47)	.607^b
Contact with animals, n (%)
Yes	9 (43)	6 (40)	.864^b
No	12 (57)	9 (60)	.864^b
Patients from rural areas, n (%)
Yes	13 (62)	8 (53)	.607^b
No	8 (38)	7 (47)	.607^b
Location, n (%)
Left kidney	12 (57)	9 (60)	.864^b
Right kidney	9 (43)	6 (40)	.864^b
Location in kidney, n (%)
Upper	3 (14)	2 (13)	.975^b
Middle	9 (43)	6 (40)
Lower	9 (43)	7 (47)
Clinical features, n (%)
Lumbar pain	12 (57)	7 (47)	.535^b
Palpable mass	8 (38)	5 (33)	.769^b
Asymptomatic	5 (24)	3 (20)	.786^b
Hematuria	1 (5)	0 (0)
Eosinophilia, n (%)
Positive	5 (24)	4 (27)	.845^b
Negative	16 (76)	11 (73)	.845^b
IHA test, n (%)
Positive	10 (48)	7 (47)	.955^b
Negative	11(52)	8 (53)	.955^b
Cyst size (cm)	8.1 ± 2.2	7.6 ± 2.0	.478^a
WHO/IWGE classification, n (%)
CE1	2 (10)	1 (7)	.924^c
CE2	12 (57)	9 (60)
CE3	7 (33)	5 (33)
CE4	0 (0)	0 (0)
CE5	0 (0)	0 (0)

Data are presented as mean ± standard deviation.

Student's t test.

Chi-squared test.

Mann–Whitney-U-test.

CE, cystic echinococcosis; IHA, indirect hemagglutination; WHO/IWGE, World Health Organization Informal Working Group on Echinococcosis.

Operation time and intraoperative bleeding amount in group 1 and group 2 were 119.6 ± 17.1/116.1 ± 17.6 minutes and 125.7 ± 27.8/113.9 ± 19.2 mL, respectively. There was no statistically significant difference between these values (P = .557, P = .167 respectively). The length of hospital stay in group 1 and group 2 was 5.9 ± 1.4/3.6 ± 0.7 days, respectively. Hospitalization duration of group 2 was statistically significantly lower (P < .001). The median follow-up period was 80 months in group 1, whereas it was 36 months in group 2. No renal or nonrenal recurrence occurred in the postoperative follow-up in either group. In addition, no adverse events related to albendazole use developed in any patient during follow-up. Intraoperative and postoperative data of the patients and statistical evaluation are shown in Table 2.

Table 2.

Intraoperative and Postoperative Outcomes of Patients According to Surgical approaches

	Group 1 (open), n = 21	Group 2 (laparoscopy), n = 15	P ^a
Operative time (minutes)	119.6 ± 17.1	116.1 ± 17.6	.557
Blood loss (mL)	125.7 ± 27.8	113.9 ± 19.2	.167
Length of hospital stay (days)	5.9 ± 1.4	3.6 ± 0.7	<.001
Complications according to Clavien classification
Grade 1	0 (0%)	1 (7%)
Grade 2	1 (5%)	0 (0%)
Follow-up duration (months)	80	36	.006
Median (min-max)	(18–26)	(16–72)	.006
Recurrence	0 (0%)	0 (0%)

Values shown in bold are statistically significant.

Data are presented as mean ± standard deviation.

P values were calculated by using Student's t test or Mann–Whitney-U test for continuous variables and chi-squared test for categorical variables.

Anaphylactic shock or death did not occur in any patient intraoperatively. In group 2, no conversions to open surgery were required. One patient in group 1 developed wound infection and healed with appropriate antibiotic treatment. In the laparoscopy group, 1 patient developed fever on the first postoperative day and recovered after antipyretic therapy.

Discussion

CE is a highly complex parasitic disease due to the involvement of different organs and tissues and its slow course.² The shell of the parasite egg opens with the acidity of the upper gastrointestinal tract. The released oncospheres penetrate its thin wall and are transported to the liver by portal circulation. They can bypass the portal filter, potentially reaching every organ.¹⁸ One of the organs where it is rarely seen is the kidneys. When the literature on the treatment of renal hydatid cysts is reviewed, although open surgeries are generally at the forefront, laparoscopic approaches were reported as case reports and case series recently. To our knowledge, there is no study comparing open and laparoscopic techniques for the treatment of renal hydatid cysts. When considered in this context, our study is the first study on this subject.

During its clinical course, hydatid cysts can pass from active stages to inactive stages, and their clinical status can range from asymptomatic forms to various complications, including fatal disease.² Cysts are usually solitary and localized in the renal cortex. Symptoms vary according to the size and extent of the cyst. Cysts that are closed and not associated with the renal pelvis may be asymptomatic. Although the most common symptom in symptomatic patients is flank pain, symptoms such as palpable mass and hematuria can also be seen.¹⁹ Lumbar pain was the most common symptom with a rate of 53% in our patient group. If the cyst opens in the urinary tract, it causes hydatiduria, which is a pathognomonic finding for hydatid cysts. Hydatiduria, which is generally microscopic, is seen in 10%–20% of the cases. Despite having high diagnostic value, gross passage is relatively rare.⁷ Unlike the literature, we did not encounter hydatiduria in any of our patients. The reason for this is that we think that it may be diagnosed at earlier stages due to the increasing use of USG today.

Diagnosis is usually based on imaging findings.¹ In general, imaging by CT or USG is used as the basic tool for diagnosis, and serology and other tests are considered complementary.²⁰ For biological reasons, early highly active and late dead cyst stages are often seronegative. Therefore, serology is disappointing in many ways. In addition, the use of serology for follow-up after treatment is very limited.²¹ In our study, the overall IHA positivity rate of our patients was 47%. Collado-Aliaga et al. found that the incidence of eosinophilia was 24.8% in CE cases and also reported that eosinophilia may often be associated with endemic, active, and complicated CE.²² When all our patients are evaluated, our eosinophilia rate was found to be 25%.

Although treatments such as surgery, PAIR (Puncture, Aspiration, Injection of protoscolicidal agent and Reaspiration), albendazole, mebendazole or other anthelmintic drugs, and watch and wait for inactive and silent cysts have been described, there is still no consensus on what is the most ideal treatment today. However, surgery remains the mainstay of treatment.^5–14

In the treatment of renal hydatid cyst, kidney-sparing surgery is possible even for large lesions. Aspiration followed by controlled evacuation of the cyst facilitates germinative membrane removal and subsequent steps. Cystectomy followed by partial pericystectomy is the most commonly used technique and can be performed regardless of the size of the cyst.¹ In general, open surgery is applied with different techniques depending on the location, size of the cyst, and the applicability of kidney-sparing surgery.³ However, due to the benign nature of the disease, enucleation, marsupialization, cystectomy and partial nephrectomy can be applied. In some cases, nephrectomy may be the only option. Recently, interest in laparoscopy has increased for the treatment of renal hydatid cysts. When the literature on laparoscopic renal hydatid cyst treatment is examined, there are generally case reports apart from an 11-disease series by Demirdag et al.^19,23–27

Laparoscopy can be performed with transperitoneal and retroperitoneal approaches for renal hydatid cyst surgery, and each has its own advantages. The transperitoneal approach is the preferred access for most surgeons and provides a wider working area. One of the concerns with laparoscopic treatment is whether the laparoscopic approach will lead to an increased incidence of intraoperative spillage. However, clinical and experimental results show a low incidence of intraoperative spillage.^13,28 In general, laparoscopic surgery is known to have less postoperative pain, better cosmetic results, less blood transfusion, and shorter hospital stay compared with open surgery. All 15 patients who we treated laparoscopically were approached transperitoneally. Although the duration of operation, intraoperative bleeding amount, and complication rates were found to be similar between patients who underwent laparoscopic surgery and open surgery, the length of stay was statistically significantly shorter in the laparoscopic surgery group. When we evaluate our results, laparoscopic surgery can be performed with similar efficacy and reliability to open surgery for the treatment of renal hydatid cysts.

Despite advances in surgical techniques and chemotherapy use, recurrence continues to be one of the main problems in the treatment of hydatid cyst disease.²⁹ In general, the recurrence rates for hydatid cyst appear to be quite variable (0%–22%) and may develop at intervals ranging from 3 months to 20 years after the first operation.³⁰ In our follow-up, no recurrence was detected in either group.

The limitations of our study are that it was retrospective, and that our total number of patients and our median follow-up period (36 months) in group 2 are relatively low. Despite these limitations, we think that our study is valuable since it is the first study on the subject.

Conclusion

In the treatment of renal hydatid cysts, kidney-sparing surgery should be recommended whenever possible due to the benign nature of the disease. The minimally invasive approach, laparoscopy, can be technically applied with the same principles as open surgery, and it has a similar efficacy and safety profile for short- and long-term results. We believe that prospective randomized studies with higher patient numbers will support our findings and increase the level of evidence.

Footnotes

Authors Contributions

All authors have made a significant contribution to the findings and methods in this article. E.V.: Research concept and design—writing the article; H.E.: Final approval of article; H.A.: Data analysis and interpretation; U.U.: Data analysis and interpretation; F.O.: Collection and/or assembly of data; K.K.: Data analysis and interpretation; L.A.: Collection and/or assembly of data; Z.G.G.: Final approval of article.

Ethics Approval

Local ethics committee approval was obtained.

Disclosure Statement

No competing financial interests exist.

Funding Information

No funding was received for this article.

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