Difficulties in Laparoscopic Renal Cyst Removal and Giant Hydronephrosis Nephrectomy

Abstract

The majority of giant hydronephrotic kidneys are nonfunctional and symptomatic, making nephrectomy the procedure of choice because of the massive size and altered anatomic relationships of these kidneys, surgical excision is challenging. The other common cause of giant hydronephrotic kidney is the presence of large renal cysts, which may be simple or associated with other pathologies. Renal cystic disease is a common incidental, radiographic, and postmortem finding. It is estimated that evidence of renal cysts exists in 50% of the adult population. The increased use of imaging modalities, such as ultrasonography and computed tomography (CT), has produced a corresponding increase in the detection of renal cystic disease. Simple renal cysts occur with an incidence of at least 20% by age 40 and 33% at age 60. Most of these lesions are asymptomatic. At times, the lesions may be associated with dull renal angle pain, flank pain, hypertension, a palpable mass, hematuria, infection, and collecting system obstruction. Certain renal cysts can be associated with other pathologic conditions, such as autosomal dominant polycystic kidney disease (ADPKD) and acquired cystic disease in chronic dialysis. Symptomatic renal cysts can be treated by percutaneous aspiration with or without injection of sclerosants, percutaneous marsupialization, open surgery, and, currently, by laparoscopic surgery by transperitoneal and retroperitoneal access with similar efficacy to open surgery and less morbidity. In this chapter, the authors present the laparoscopic approaches for giant kidneys of varied pathology with an emphasis on the surgical options used in their management.