DECORTICATION IN SOLITARY CYSTIC AND ADULT POLYCYSTIC KIDNEY DISEASE 705 had sudden recurrent pain 3 months postoperatively is cur- rently considering a repeat procedure on a solitary kidney. Baseline creatinine was 3.5 mg./dl. and i t i s now 3.8 mg./dl. 1 year later. The other patient who is not now pain-free was free of symptoms for 4 years after the initial procedure. A repeat laparoscopic procedure as well as subsequent open surgical cyst decortication were unsuccessful in this case.

After a repeat operation 2 patients have been pain-free throughout followup, except for a brief period at the time of the second procedure, for 36 and 51 months, respectively. Few series have documented followup for this long and the etiology of late pain recurrence is unknown. It may be pre- sumed to result from the formation of new cysts and enlarge- ment of previously existing small or internal cysts.

Brown et a1 correlated CT findings of cyst ablation with pain relief in polycystic kidney disease cases.4 We did not note much change in the radiographic appearance of kidneys in polycystic kidney disease and the changes that occurred did not appear to correlate well with pain relief. A possibility is that pain relief is related to an overall decrease in cyst burden, not individual cysts. Another suggestion is that pain relief may partially be due to renal neurolysis, that is the effect of mobilizing the kidney may tend to disrupt the neural pathways responsible for pain perception in the renal area.

Laparoscopic marsupialization of simple renal cysts is be- coming established as a viable option to open surgery in symptomatic patients.4-8 We perform percutaneous aspira- tion with or without a sclerosing agent as a diagnostic and therapeutic maneuver to determine whether pain is relieved by cyst decompression. If the cyst and pain recur, laparo- scopic marsupialization is offered.

Cyst walls must always be sent for pathological analysis and the interiors of cysts must be carefully inspected for tumor. Each patient must be aware that partial or total nephrectomy may be required if tumor is found. Intraopera- tive external sonography may be useful in some cases for localizing targeted cysts but we have not used this method. When this technique is used, the abdomen should be desuf- flated before scanning.4 In the future the laparoscopic ultra- sound probe may prove more useful for intraoperative cyst targeting.

Laparoscopic exploration for complex cysts is new and it should be limited to carefully selected patients at this time. Patients must be informed of the risks inherent in this pro- cedure, especially the theoretical risk of cancer cell migration if a tumor bearing cyst is opened. In this series complex cysts were limited to those in Bosniak category 11, that is mini- mally complicated benign cysts with some radiological find- ings that cause concern.6 These may include septated, mini- mally calcified, infected and high density cysts. These patients did well in our series and cyst ablation was con- firmed on followup renal sonography.

Reduction of cyst volume for symptomatic management of autosomal dominant polycystic kidney disease. J. Urol., 157: 620, 1987.

3. Teichman, J. M. and Hulbert, J. C.: Laparoscopic marsupializa- tion of the painful polycystic kidney. J. Urol., 153 1105, 1995.

4. Brown, J. A,, Torres, V. E., King, B. F. and Segura, J. W.: Laparoscopic marsupialization of symptomatic polycystic kid- ney disease. J. Urol., 156: 22, 1996.

5. Munch, L. C., Gill, I. S. and McRoberts, W.: Laparoscopic retro- peritoneal renal cystectomy. J. Urol., 151: 135, 1994.

6. Bosniak, M. A.: The current radiological approach to renal cysts. Radiology, 158 1, 1986.

7. Hulbert, J. C., Shepard, T. G. and Evans, R. E.: Laparoscopic surgery for renal cystic disease. J. Urol., part 2, 147: 433A, abstract 882, 1992.

8. Morgan, C., Jr. and Rader, D.: Laparoscopic unroofing of a renal cyst. J. Urol., 148: 1835, 1992.

9. Nieh, P. T. and Bihrle, W., 111: Laparoscopic marsupialization of massive renal cyst. J. Urol., 150 171, 1993.

10. Rubenstein, S. C., Hulbert, J. C., Pharand, D., Schuessler. W. M., Vancaillie, T. G. and Kavoussi, L. R.: Laparoscopic ablation of symptomatic renal cysts. J. Urol., 1M): 1103, 1993.

11. Gabow, P. A., Grantham, J. J. and Bennett, W. N.: Gene testing in ADPKD: results of the National Kidney Foundation work- shop. h e r . J. Kidney Dis., 1 3 85, 1989.

12. Delaney, V. B., Adler, S. and Bruns, F. J.: Autosomal dominant polycystic kidney disease: presentation, complications and prognosis. Amer. J. Kidney Dis., 5 104, 1985.

13. Zeier, M., Gerberth, S. and Ritz, E.: Autosomal dominant poly- cystic kidney disease: clinical problems. Nephron., 4 9 177, 1988.

14. Bean, W. J.: Renal cysts: treatment with alcohol. Radiology, 138: 329, 1981.

15. Holmberg, G. and Hietala, S. 0.: Treatment of simple renal cysts by percutaneous puncture and instillation of bismuth phos- phate. Scand. J. Urol. Nephrol., 23 207, 1989.

16. Hulbert, J., Hunter, D. and Castefieda-Zuniga, W.: Percutaneous intrarenal marsupialization of a perirenal cystic collection- endocystolysis. J. Urol., 139 1039, 1988.

17. Rovsing, T.: Treatment of multilocular renal cyst with multiple punctures. Hospitalstid, 4: 105, 1911.

EDITORIAL COMMENT

CONCLUSIONS

Laparoscopic renal cyst decortication is becoming estab- lished as an effective, minimally invasive treatment for pain- ful cystic disease of the kidney with results similar to those of open surgery. Good pain relief for patients with autosomal dominant polycystic kidney disease has been demonstrated and a repeat procedure may be successful for recurrent pain. Laparoscopic cyst decortication appears to be universally successful for painful, solitary or multiple renal cysts, pro- vided the cysts are targeted accurately.

REFERENCES

1. Elzinga, L. W., Barry, J. M., Torres, V. E., Zincke, H., Wahner, H. W., Swan, S. and Bennett, W. M.: Cyst decompression for autosomal dominant polycystic kidney disease. J. h e r . Soc. Nephrol., 2 1219, 1992.

2. Bennett, W. M., Elzinga, L., Golper, T. A. and Barry, J. M.:

10-year followup of patients who underwent open surgical cyst deco- rtication for autosomal dominant polycystic kidney disease sug- gested maintenance of pain-free status, and stabilization of renal function and blood pressure.' The prospect of offering patients with

Laparoscopic decortication of renal cysts is a relatively new addi- tion to the myriad treatments described for renal cysts. It is impor- tant to distinguish the etiology of cystic renal disease when review- ing the results of laparoscopic intervention, that is whether it involves a single simple peripheral cyst, single peripelvic cyst or multiple peripheral and peripelvic cysts, such as autosomal domi- nant polycystic kidney disease. Most symptomatic simple cysts are of a peripheral nature and they can be managed with percutaneous drainage and sclerosis. However, in those few simple cysts resistant to this intervention decortication is easily achieved laparoscopically, either transperitoneally or retroperitoneally. In contrast, the peripelvic cyst is a rare simple cyst that is considered a contraindi- cation to percutaneous sclerosis. These cysts can be effectively man- aged laparoscopically, although the procedure is more complex than decortication of a simple peripheral cyst. The peripelvic cyst usually lies between the major hilar vessels and the renal pelvis and, thus, laparoscopic cyst dissection is more complicated and demanding. The situation in autosomal dominant polycystic kidney disease is distinct from that in the single simple or single peripelvic cyst. Autosomal dominant polycystic kidney disease involves the most challenging and tedious decortication procedure. Therefore, in a comparative review it is important that each cyst disease group be evaluated separately to validate the results of the final analysis for each type of renal cyst condition. Furthermore, in high risk patients with auto- somal dominant polycystic kidney disease followup information on renal function and hypertension is also needed to determine whether there are any adverse effects of cyst decortication.

Laparoscopic cyst decortication may have the most significant impact on the treatment of patients with autosomal dominant poly- cystic kidney disease (reference 1 in article). A recent report on a

706 DECORTICATION IN SOLITARY CYSTIC AND ADULT POLYCYSTIC KIDNEY DISEASE

this disease these clinical results with a minimally invasive surgical technique is encouraging and daunting.

The principles of laparoscopic cyst decortication for autosomal dominant polycystic kidney disease include a transperitoneal ap- proach to maximize the number of cysts unroofed a t a single session and allow cyst marsupialization into the peritoneal cavity in an effort to decrease cyst reformation. These kidneys are usually large and the transperitoneal approach ensures adequate exposure of the whole organ. It is our goal to duplicate open cyst decortication in autosomal dominant polycystic kidney disease and, thus, the best results are obtained when as many cysts as possible are unroofed. To this end at Washington University we have found that the intraop- erative laparoscopic ultrasound probe is useful, because it increases the number of deeper cysts that can be identified and unroofed. Using a combined laparoscopic visual and ultrasound identification technique decortication has been done in a maximum of 642 cysts. Instillation of indigo carmine solution for identifying the upper col- lecting system during the decortication procedure is helpful to min- imize the risk of injury to the collecting system. These cases have a long operative time, an average of 5 hours, although to date results have been encouraging in OUT 8 cases at 12 months of followup (range 3 to 36). The analog pain scale showed an 85% decrease in pain. Notably hypertension improved or resolved in 4 patients, while renal function remained stable in 6, improved in 1 and decreased slightly (creatinine increase of 0.3 mgJdl.) in 1.2

To determine whether laparoscopic cyst decortication has the same efficacy as open surgical cyst decompression in autosomal dominant polycystic kidney disease, careful long-term followup is necessary. Comparative preoperative and postoperative CT will en- able documentation of cyst reduction and monitor any new cyst formation or growth after laparoscopic cyst decortication. Long-term

evaluation of blood pressure, creatinine clearance, split function renal scans, analog pain scales and/or analog quality of life question- naires will be paramount in determining the clinical effects of cyst decortication on renal function, and whether it will ultimately im- prove patient quality of life and survival. The demonstration that laparoscopic cyst decortication stabilizes renal function, decreases patient pain and minimizes hypertension would be a significant advance in the management of autosomal dominant polycystic kid- ney disease. However, presently we limit this approach to patienb with autosomal dominant polycystic kidney disease who have signif- icant discomfort and impaired quality of life due only to the presence of large renal cysts. From this patient population insights on the impact of laparoscopic autosomal dominant polycystic kidney disease cyst decortication on blood pressure and renal function will eventu- ally be forthcoming.

Elspeth M. McDougall Department of Surgery Division of Urologic Surgery Washington University School of Medicine St. Louis, Missouri

1. Ye, M., Chen, J., Zhang, L., Kong, L., Wang, W. and Ma, B.: Long-term results of cyst decapitating decompression (CDD) operation for autosomal dominant polycystic disease (AD- PKD). J. Urol., part 2, 167: 286, abstract 1114, 1997.

2. Hoenig, D. M., Elbahnasy, A. M., Shalhav, A. L., McDougall, E. M. and Clayman, R. V.: Laparoscopic management of auto- somal dominant polycystic kidney disease. J. Endourol., 11: S126, abstract P6-13, 1997.