Optimized Retroperitoneoscopic Excision of Large (>25 cm) Adult Polycystic Kidneys Using 3-Dimensional Image Reconstruction and Preresection Ultrasound-Guided Aspiration

Background. Laparoscopic excision of large polycystic kidneys remains a challenging procedure. Most of the literature describes transperitoneal approaches. Alterations in anatomy due to size of kidneys can make vascular and hilar control difficult. Retroperitoneal access with direct control of pedicle avoids risks without dissection for structures anterior to the kidneys. The technique of retroperitoneoscopic excision of massively enlarged kidneys is described with early outcomes. Methods. Patient DICOM images of kidneys were segmented and reconstructed for 3-dimensional visualization before surgery. Total excision of large polycystic kidneys was performed in 10 patients (11 procedures). After creation of retroperitoneal space, renal pedicle dissection was started with the incision of thinned out Gerota’s fascia. Occasionally aspiration of large cysts using ultrasound assistance created space for precise dissection. Following control of vascular pedicle under laparoscopic vision, further aspiration of cysts was accomplished with the help of 3-dimensional reconstructed kidney. Postaspiration, remaining renal specimen was extracted through a small incision using an endobag or as an intact specimen. Results. The operative time was between 180 and 240 minutes (median 200 minutes). Intraoperative blood loss was 100 to 300 mL (median 175 mL). Median time to control pedicle was 12 minutes (range 10-25 minutes). The postoperative periods were uneventful, except for blockage of arteriovenous fistula in 1 patient. Mean hospital stay was 7 days (range 6-14 days). Conclusions. The retroperitoneasocopic approach to large polycystic kidneys under the guidance of 3-dimensional image reconstruction, occasionally with the assistance of ultrasound aspiration is technically feasible, safe, with good perioperative outcomes. It facilitates early control of vascular pedicle with minimal risk of intraoperative bleeding.