Int Urol Nephrol DOI 10.1007/s11255-014-0741-y
UROLOGY - ORIGINAL PAPER
Treatment of renal parapelvic cysts with a flexible ureteroscope Qizhan Luo • Xiaobo Zhang • Hequn Chen Zhen Liu • Xiong Chen • Yuanqi Dai • Zhongwei Zhao
•
Received: 15 February 2014 / Accepted: 8 May 2014 Ó Springer Science+Business Media Dordrecht 2014
Abstract Purpose The aim of this study was to assess efficacy and safety of a flexible ureteroscope to treat renal parapelvic cysts. Treatment goals included avoidance of injury to renal vessels or hilar structure and minimizing the recurrence of cysts. Patients and methods Renal parapelvic cysts from 15 patients that were incised and drained with a flexible ureteroscope were evaluated retrospectively between October 2011 and May 2013. Mean operation time, estimated blood loss and time of hospital stay were evaluated. Symptomatic and radiologic results, conducted by computed tomography or color Doppler ultrasound, were analyzed after surgery. Results According to the Dindo-Clavien classification, no major complications were observed during the different types of surgery. One patient exhibited red hematuria (mild), while bladder irritation symptoms (mild) occurred in three cases in the hospital and in two cases in the first postoperative month (moderate). Average total operation times, mean duration for the incision in the renal parapelvic cyst wall and mean estimated blood loss were 31 ± 8 min, 13 ± 2 min and 20 ± 5 ml, respectively. Mean hospital length of stay was 3 days. Radiologic success was defined as no recurrence of the cyst or a reduction in cyst size by at least half. In one case, cyst size did not reduce to half of the previous size, whereas cyst sizes were reduced to less than half of the previous size in four cases. No cysts were detected in the other cases after 6 or 12 months.
Q. Luo X. Zhang (&) H. Chen Z. Liu X. Chen Y. Dai Z. Zhao Department of Geriatrics, Study Group of Urology, Xiangya Hospital Central-South University, Changsha 410008, Hunan Province, China e-mail: [email protected]
Conclusions Feasibility, safety and efficacy of the flexible ureteroscope for treatment of retrograde renal parapelvic cysts were demonstrated using appropriate patient selection and skilled surgical technique. Keywords Flexible ureteroscope Renal parapelvic cyst Incision Drainage
Introduction Benign renal cysts are common entities that increase in occurrence with age [1]. Fortunately, most patients are treated conservatively because cysts are small and clinical symptoms are rarely apparent. With severe symptoms, however, treatment of renal cysts requires surgical intervention. Renal parapelvic cysts constitute a rare form of renal cyst that is usually associated with lower back pain. Parapelvic cysts are found in approximately 1.25–1.50 % of autopsy cases [2]. As they expand, if the cystic pressure exceeds the pressure of intrapelvic urine, progressive obstruction ensues [3]. Symptomatic renal cysts can be treated by open exploration and nephrectomy [3–5], percutaneous aspiration with or without injection of sclerosants, ethanol, percutaneous ablation [6–8], antegrade percutaneous nephroscopy [9] or laparoscopic renal-sparing cyst excision, unroofing, decortication and ablation [10–15]. Unlike simple renal cysts, renal parapelvic cysts, which are in close proximity to the pelvis and major calyces, are located on or probably originate in the hilus of the kidneys [3]. A complete form of transurethral translumenal endoscopic surgery has been successfully employed, including use of flexible retrograde ureteroscopy [16, 17]. However,
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avoidance of injury to the renal vessels or hilar structure and recurrence of renal parapelvic cysts are not extensively considered in the two aforementioned studies because of limited sample size (8 cases). We summarize our initial clinical experience using the flexible ureteroscope in the management of renal parapelvic cysts.
Table 1 Characteristics of patient population in study Case parameters
Value
Patients, (n)
15
Mean age (years)
53 years, range 42–68 years
Cysts per patient, (n)
15
Largest cyst size, (cm) (before surgery)
6.1 cm (range 4.5–7.8)
Materials and methods
Largest cyst size, (cm) (after surgery)
1.2 cm (range 0–3.1)
Patients
Visual analog scale (VAS) (before surgery)
4.70 ± 1.68
Visual analog scale (VAS) (after surgery)
Three cases had slight paroxysmal swelling pain because of bladder spasm, but the time of bladder spasm was very short. Two cases complained of a dull ache when they left the hospital. All cases did not complain of lower pain
This study was approved by the Xiangya Hospital Central South University Research Ethics Committee (Hunan, China). Written informed consent was obtained from all patients for entry into this study after full explanation of the procedure. Our institution reported 15 cases of parapelvic renal cysts between October 2011 and May 2013. These cases were all treated by an operation using a flexible ureteroscope. A total of nine men and six women (mean age 53 years, range 42–68), with renal parapelvic cysts confirmed by computerized tomography (CT), were admitted with initial complaints of abdominal or flank pain, recurrent urinary tract infection or hematuria. The visual analog scale (VAS) was used for the assessment of variation in intensity of pain. VAS was 4.70 ± 1.68 before surgery. Patient characteristics are listed in Table 1. Two patients had previously undergone cyst aspiration, but all cases had previous unsuccessful treatments. Because of continuous abdominal or flank pain (15 cases), recurrent urinary tract infection (2 cases) or hematuria (3 cases), all patients were strongly advised to be treated surgically. Inclusion criteria for the study included: the presence of a renal parapelvic cyst, compression of the renal collecting system by the cyst and/or previous unsuccessful treatments. Exclusion criteria included: cardiopulmonary insufficiency, coagulation disorders and/or lower urinary obstruction. Flat sweep and enhanced CT scans were necessary to demonstrate renal parapelvic cysts, which compressed the renal collecting system (Fig. 1). The CT was also necessary to help distinguish among the various potential classes of abnormalities, including renal parapelvic cysts, peripheral renal cysts, hydronephrosis, renal stones and other abnormalities. The largest mean cyst size was 6.1 cm (range 4.5–7.8 cm). Patients with complex cysts, defined as the presence of more than two cysts, were excluded from the present study. Procedures All patients were given general anesthesia before surgery. A 4F guidewire was advanced transureterally to the renal
123
Location/presentation Left
9
Right
6
Renal pelvis obstruction
5
Upper pole obstruction
7
Lower pole obstruction
3
Symptoms (n) Abdominal or flank pain
15
Hematuria
3
Recurrent urinary tract infection
2
Number of patients who used ultrasound (during the operations)
6
Number of patients
N
Whose cyst size was not reduced to half of the previous size
1 case
Whose cyst size was not reduced to half of the previous size
4 cases
Whose cysts disappeared Mean total operation time
10 cases 31 ± 8 min
Mean duration of incision of the renal cyst
13 ± 2 min
Mean estimated blood loss
20 ± 5 ml
Mean hospital stay
3 days (range 2–4 days)
pelvis with the ureteroscope to guide the ureteral access sheath, which enables access to the renal pelvis through the ureter. The study was performed with an 8.5F electronic flexible ureteroscope (UFR-P3, Olympus; Tokyo, Japan) and fiber flexible ureteroscope. The first patient was treated with the fiber flexible ureteroscope, and the other patients were treated with the electronic flexible ureteroscope. Inside the ureteropelvic region, the cyst wall was generally
Int Urol Nephrol
Fig. 1 The CT shows the renal cysts before the operation, in the first postoperative month, and in the sixth postoperative month. The first picture shows renal parapelvic cysts compressing the renal collecting
system. The second picture shows cysts in the first postoperative month, and the ureteral stent is shown by the arrow. The third picture shows cysts in the sixth postoperative month
found to be compressing the collecting system and was noted to be obstructing the urinary collecting system with (or without) the guidance of B ultrasound. Direct ureteroscopic vision was used to guide a 200-lm laser fiber (0.8 W/hz, 20 Hz; FlexiFib, LisaLaser; Katlenburg-Lindau, Germany) to incise the cyst wall that was adjacent to the collecting system. The full-thickness, openincised thin area was about 2–4 cm to communicate with the collecting system. To avoid closing the cyst margins, the Ho–YAG laser was used to completely coagulate the margin of incision, covering the entire incised margin. A 5F Double-J stent, which was removed in the clinic after 4 weeks, was placed with the proximal end coiled in the cyst cavity to drain the cystic fluid [17]. To avoid misdiagnosis of cystic renal cell carcinoma, the cyst interior was completely examined and a portion of dissociative renal wall, which was incised by the Ho–YAG laser, was biopsied with the ureteroscopic biopsy. CT scans after 1, 6 and/ or 12 months showed no signs of recurrence of cysts or stones.
was controlled with solifenacin. One patient exhibited minor hematuria, but these symptoms disappeared after the third postoperative day. Average total operation times, mean duration of incision of the renal parapelvic cyst and mean estimated blood loss were 31 ± 8 min, 13 ± 2 min and 20 ± 5 ml, respectively. The mean length of hospital stay was 3 days (range 2–4 days). All pathology findings revealed benign renal cysts. Radiologic success was defined as no recurrence of the cyst or a reduction in cyst size by at least 50 %. CT scans showed that in one case, cyst size did not decrease to half of its previous size, and in four cases, cyst size was less than half of the previous size after 6 months. CT or color Doppler ultrasound showed that all cysts disappeared in the other cases after 6 or 12 months.
Results There were no intraoperative complications. Patients reported marked relief or disappearance of pain, and there was clinical observation of hematuria disappearance after the operation. No patients reported lower back pain or discomfort during the hospital stay after surgery. However, slight swelling and bladder spasm occurred in three cases in the hospital; the time of bladder spasm was very short, and two cases complained of paroxysmal pain when they were discharged from the hospital after surgery. Their pain
Discussion With the development of novel therapeutic techniques for treating renal cysts, minimally invasive (keyhole) surgical procedures [10–15] have gradually replaced open surgery [3]. Aspiration and sclerotherapy are associated with a high recurrence rate, and accidental spillage of a sclerosing agent can lead to severe peri-renal inflammation, abscess formation, fever, pain and secondary ureteropelvic junction obstruction [18–20]. Because of adhesions around the retroperitoneal area, previous renal surgery makes laparoscopic access more difficult, and obesity makes laparoscopic procedures more time-consuming due to the increased need for dissection [11, 14]. Significant complications (e.g., hemorrhage, collecting system leak and urinary fistula) may result from fulgurating the base of the
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Fig. 2 Photograph of typical cyst walls observed in patients in this study. The color of the wall is gray or chic blue, the cyst wall is without vessel pulsation or the selected cyst wall is similar to a translucent membrane
renal cysts to destroy the secretory activity of the remaining cyst wall [15, 21]. While no serious complications have been noted for percutaneous ablation with cyst resection using a resection loop for the prostate [22] or percutaneous intrarenal marsupialization of symptomatic peripelvic renal cysts [9], other procedures require longer mean operative times. Another reported technique, percutaneous resection, also exhibited no complications, but the mean operative time was 55 min, which is considerably longer than in our study (31 ± 8 min), and the technique did not show simple renal cysts [23]. Percutaneous endocystolysis [24] is another technique that has been used for resolution of renal cysts. The mean operative time is slightly longer than demonstrated in our study, but there have only been five cases reported and the incidence of cyst perforation was 12.5 % [24]. Complete transurethral translumenal endoscopic surgery has been successfully developed and includes flexible retrograde ureteroscopy [16, 17]. However, the two studies describing the procedure provided little discussion of the need to avoid injuring the renal vessels or hilar structure and recurrence of renal parapelvic cysts due to small patient numbers (i.e., only 8 cases). In the present work, we describe our initial clinical experience using the flexible ureteroscope in the management of renal parapelvic cysts. Keys to success in treating renal parapelvic cysts are to avoid injuring the renal vessels or hilar structure and minimizing cyst recurrence. The first key question to consider is how the parapelvic cyst wall can be found. First, a flat sweep and enhanced CT scans are necessary to demonstrate the presence of renal parapelvic cysts, and the CT shows whether the cysts compress the renal collecting system. Subsequently, the use of a high-definition camera system may be very
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important in finding the cyst wall. In our practice, we report on 14 cases in which the cyst wall was detected with an electronic flexible ureteroscope, because we found that the fiber flexible ureteroscope provided a dim image in those surgeries. Third, the cyst wall curves toward the collecting system and may show a circular shape. The cyst wall may compress the renal calyceal neck, altering how it is viewed in the image. Fourth, the color of the wall is gray or chic blue, or the cyst wall is without the vessel pulsation or the selected cyst wall is similar to a translucent membrane (Fig. 2). Finally, color Doppler ultrasound is valuable in helping to find the parapelvic cyst wall if we have difficulties or uncertainties with the methods described above. The second key question is how to deal with the parapelvic cyst wall. Our practice is similar to the experience reported by others [16, 17], but exhibits some important differences, as described below. The selected cyst wall is similar to a translucent membrane. In this situation, the incised cyst does not recur because the margin of incision does not produce scar tissue. Furthermore, if the size of ‘‘the translucent membrane’’ is not large enough, we increase the size of the incision around the cyst wall and completely coagulate it. Subsequently, if the incised cyst wall, which is not similar to the translucent membrane, is without vessel pulsation and the color of the wall is pale and dim, the size of the incision and the completely coagulated cyst wall in this situation should be larger than the size of the incised cyst wall in the first or second situation. The margin of incision may produce scar tissue if the incised size is not large enough, which may contribute to development of a diverticulum or may make the incised cyst wall close. Next, if we find the cyst wall does not have any differences from the collecting system under direct
Int Urol Nephrol
Fig. 3 Use of B ultrasound to guide surgeons to the proper site to incise the cyst wall. When the Ho–YAG laser incised the parapelvic cyst wall, hyperechogenicity occurred in the B ultrasonography (shown by the arrow)
ureteroscopic vision, the B ultrasound guides us to incise the cyst wall (Fig. 3). Subsequently, we performed electroresection and electrocautery of the incision at a lowenergy setting to avoid hemorrhage with 200-lm holmium laser fiber (0.8 W/hz, 20 Hz). In theory, the green light laser may be safer than the holmium laser [25]. However, the green light laser was in short supply in our hospital. Li and colleagues [17] reported a portion of the cyst wall was first harvested by ureteroscopic biopsy forceps for histopathology examinations. In contrast, our experience was that we send the dissociated cyst wall that was not cut by ureteroscopic biopsy forceps but was incised by Ho–YAG laser, for histopathology examination, to avoid causing hemorrhage. Next, when the cyst wall is incised, the thickness of the margin of the incised cyst wall should be observed. If the margin of the incised cyst wall is relatively thick, incision of the cyst wall should be stopped because this situation may increase the risk of bleeding. Finally, similar to Li and colleagues [17], a 5F double-pigtail ureteral stent was positioned with the proximal end coiled in the cyst cavity [17]. We consider that the double-pigtail ureteral stent not only provides for efficient drainage but can also avoid closing of the incised cyst wall. In our study, average total operation times, mean length of hospital stay and mean estimated blood loss were similar to those reported by Li and colleagues [17]. The mean duration of the incision procedure for the renal parapelvic cyst is only 13 ± 2 min. We spend more time finding the cyst wall, especially when the cyst wall does not exhibit clear differences from the collecting system. In our hospital, parapelvic cysts are treated by retroperitoneoscopic decortication by one group of physicians [15]. In this study, the mean estimated blood loss is obviously less than that for the parapelvic cysts treated by retroperitoneoscopic
decortication. Mean hospital stay was slightly less than that for the parapelvic cysts treated by retroperitoneoscopic decortication. In our study, cyst size in one case was not reduced to half of its previous size after the twelfth postoperative month. Because we found that the margin of the incised cyst wall was thick, the incision process was stopped to avoid bleeding. The full-thickness, open-incised area was\2 cm. With collapse of the cyst or healing of the cyst wall, the parapelvic cyst wall may close or the cyst may become a diverticulum, which may result in flank pain, hematuria, recurrent urinary tract infections or symptomatic stones. Minor hematuria occurred in one case but disappeared after the second postoperative day. We found that the patient’s pelvis–ureter junction had slight stricture during the operation. We assessed the reason why the patient exhibited minor hematuria and concluded that the flexible ureteroscope may have injured the ureteral mucosa because of the slightly narrow pelvis–ureter junction. Three patients felt slight swelling pain in the bladder area during their hospital stay. However, when bladder irritation did occur, the foley was withdrawn because we believe that the time of foley insertion should be as short as clinically possible. Two patients complained of paroxysmal pain. We speculated that bladder irritation symptoms occurred in these two cases in the first postoperative month and were later controlled with solifenacin. Additionally, a tortuous, kinked or angulated ureter makes the ureteroscopy procedure more difficult. For this problem, the morphology of the ureter was determined with intravenous urography (IVU) and shown to have various degrees of tortuous, kinked or angulated ureters. Therefore, IVU was conducted on the patients before the operation to view the ureter. If the patient has a tortuous, kinked or angulated ureter, we
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suggest placement of a double-J ureteral catheter before surgery. After an additional month, the patient is recommended to undergo surgery. In conclusion, we demonstrate the feasibility, safety and effectiveness of the flexible ureteroscope for retrograde treatment of renal parapelvic cysts. This was accomplished through appropriate patient selection and skilled surgeons.
References 1. Okeke AA, Mitchelmore AE, Keeley FX, Timoney AG (2003) A comparison of aspiration and sclerotherapy with laparoscopic deroofing in the management of symptomatic simple renal cysts. BJU Int 92:610–613 2. Lee FTJ, Thornbury JR (1998) The Urinary Tract. In: Paul and Juhl’s Essentials of Radiologic Imaging 7th edition. (eds) Juhl JH, Crummy AB, Kuhlman JE. Lippincott Williams &Wilkins, Philadelphia p 683 3. Amis EJ, Cronan JJ, Pfister RC (1983) The spectrum of peripelvic cysts. Br J Urol 55:150–153 4. Amar AD, Das S (1984) Surgical management of benign renal cysts causing obstruction of renal pelvis. Urology 24:429–433 5. Rubenstein SC, Hulbert JC, Pharand D et al (1993) Laparoscopic ablation of symptomatic renal cysts. J Urol 150:1103–1106 6. Korets R, Mues AC, Gupta M (2011) Minimally invasive percutaneous ablation of parapelvic renal cysts and caliceal diverticula using bipolar energy. J Endourol 25(5):769–773 7. Choi YD, Cho SY, Cho KS, Lee DH, Lee SH (2007) Percutaneous treatment of renal cysts with OK-432 sclerosis. Yonsei Med J 48:270–273 8. Holmberg G, Hietala SO (1989) Treatment of simple renal cysts by percutaneous puncture and instillation of bismuth–phosphate. Scand J Urol Nephrol 23:207–212 9. Shao ZQ, Guo FF, Yang WY et al (2013) Percutaneous intrarenal marsupialization of symptomatic peripelvic renal cysts: a singlecentre experience in China. Scand J Urol 47:118–121 10. Yoder BM, Wolf JJ (2004) Long-term outcome of laparoscopic decortication of peripheral and peripelvic renal and adrenal cysts. J Urol 171(2 Pt 1):583–587 11. Roberts WW, Bluebond-Langner R, Boyle KE et al (2001) Laparoscopic ablation of symptomatic parenchymal and peripelvic renal cysts. Urology 58(2):165–169
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12. Doumas K, Skrepetis K, Lykourinas M (2004) Lapyroscopic ablation of symptomatic peripelvic renal cysts. J Endourol 18(1):45–48 13. Hoenig DM, McDougall EM, Shalhav AL et al (1997) Laparoscopic ablation of peripelvic renal cysts. J Urol 158(4): 1345–1348 14. Camargo AH, Cooperberg MR, Ershoff BD et al (2005) Laparoscopic management of peripelvic renal cysts: University of California, San Francisco, experience and review of literature. Urology 65(5):882–887 15. Chen Z, Chen X, Luo YC et al (2011) Retroperitoneoscopic decortication of symptomatic peripelvic renal cysts: Chinese experience. Urology 78(4):803–807 16. Kavoussi LR, Clayman RV, Mikkelsen DJ et al (1991) Ureteronephroscopic marsupialization of obstructing peripelvic renal cyst. J Urol 146(2):411–444 17. Li EC, Hou JQ, Yang LB et al (2011) Pure natural orifice translumenal endoscopic surgery management of simple renal cysts: 2-year follow-up results. J Endourol 25(1):75–80 18. Lang EK (1977) Renal cyst puncture and aspiration: a survey of complications. Am J Roentgenol 128(5):723–727 19. Camacho MF, Bondhus MJ, Carrion HM et al (1980) Ureteropelvic junction obstruction resulting from percutaneous cyst puncture and intracystic isophendylate injection: an unusual complications. J Urol 124(5):713–714 20. Skolarikos A, Laguna MP, de la Rosette JJ (2012) Conservative and radiological management of simple renal cysts: a comprehensive review. BJU Int 110:170–178 21. Porpiglia F, Fiori C, Billia M et al (2009) Retroperitoneal decortication of simple renal cysts vs. decortication with wadding using perirenal fat tissue: results of a prospective randomized trial. BJU Int 103(11):1532–1536 22. Shah JB, Whitman C, Lee M, Gupta M (2007) Water under the bridge: 5-year outcomes after percutaneous ablation of obstructing parapelvic renal cysts. J Endourol 21:1167–1170 23. Kang Y, Noble C, Gupta M (2001) Percutaneous resection of renal cysts. J Endourol 15:735–739 24. Busato WJ, Bettega LB (2010) Percutaneous endocystolysis, a safe and minimally invasive treatment for renal cysts: a 13-year experience. J Endourol 24:1405–1410 25. Lukacs B, Loeffler J, Bruyere F et al (2012) Photoselective vaporization of the prostate with green-light 120-W laser compared with monopolar transurethral resection of the prostate: a multicenter randomized controlled trial. Eur Urol 61(6): 1165–1173
UROLOGY - ORIGINAL PAPER
Treatment of renal parapelvic cysts with a flexible ureteroscope Qizhan Luo • Xiaobo Zhang • Hequn Chen Zhen Liu • Xiong Chen • Yuanqi Dai • Zhongwei Zhao
•
Received: 15 February 2014 / Accepted: 8 May 2014 Ó Springer Science+Business Media Dordrecht 2014
Abstract Purpose The aim of this study was to assess efficacy and safety of a flexible ureteroscope to treat renal parapelvic cysts. Treatment goals included avoidance of injury to renal vessels or hilar structure and minimizing the recurrence of cysts. Patients and methods Renal parapelvic cysts from 15 patients that were incised and drained with a flexible ureteroscope were evaluated retrospectively between October 2011 and May 2013. Mean operation time, estimated blood loss and time of hospital stay were evaluated. Symptomatic and radiologic results, conducted by computed tomography or color Doppler ultrasound, were analyzed after surgery. Results According to the Dindo-Clavien classification, no major complications were observed during the different types of surgery. One patient exhibited red hematuria (mild), while bladder irritation symptoms (mild) occurred in three cases in the hospital and in two cases in the first postoperative month (moderate). Average total operation times, mean duration for the incision in the renal parapelvic cyst wall and mean estimated blood loss were 31 ± 8 min, 13 ± 2 min and 20 ± 5 ml, respectively. Mean hospital length of stay was 3 days. Radiologic success was defined as no recurrence of the cyst or a reduction in cyst size by at least half. In one case, cyst size did not reduce to half of the previous size, whereas cyst sizes were reduced to less than half of the previous size in four cases. No cysts were detected in the other cases after 6 or 12 months.
Q. Luo X. Zhang (&) H. Chen Z. Liu X. Chen Y. Dai Z. Zhao Department of Geriatrics, Study Group of Urology, Xiangya Hospital Central-South University, Changsha 410008, Hunan Province, China e-mail: [email protected]
Conclusions Feasibility, safety and efficacy of the flexible ureteroscope for treatment of retrograde renal parapelvic cysts were demonstrated using appropriate patient selection and skilled surgical technique. Keywords Flexible ureteroscope Renal parapelvic cyst Incision Drainage
Introduction Benign renal cysts are common entities that increase in occurrence with age [1]. Fortunately, most patients are treated conservatively because cysts are small and clinical symptoms are rarely apparent. With severe symptoms, however, treatment of renal cysts requires surgical intervention. Renal parapelvic cysts constitute a rare form of renal cyst that is usually associated with lower back pain. Parapelvic cysts are found in approximately 1.25–1.50 % of autopsy cases [2]. As they expand, if the cystic pressure exceeds the pressure of intrapelvic urine, progressive obstruction ensues [3]. Symptomatic renal cysts can be treated by open exploration and nephrectomy [3–5], percutaneous aspiration with or without injection of sclerosants, ethanol, percutaneous ablation [6–8], antegrade percutaneous nephroscopy [9] or laparoscopic renal-sparing cyst excision, unroofing, decortication and ablation [10–15]. Unlike simple renal cysts, renal parapelvic cysts, which are in close proximity to the pelvis and major calyces, are located on or probably originate in the hilus of the kidneys [3]. A complete form of transurethral translumenal endoscopic surgery has been successfully employed, including use of flexible retrograde ureteroscopy [16, 17]. However,
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avoidance of injury to the renal vessels or hilar structure and recurrence of renal parapelvic cysts are not extensively considered in the two aforementioned studies because of limited sample size (8 cases). We summarize our initial clinical experience using the flexible ureteroscope in the management of renal parapelvic cysts.
Table 1 Characteristics of patient population in study Case parameters
Value
Patients, (n)
15
Mean age (years)
53 years, range 42–68 years
Cysts per patient, (n)
15
Largest cyst size, (cm) (before surgery)
6.1 cm (range 4.5–7.8)
Materials and methods
Largest cyst size, (cm) (after surgery)
1.2 cm (range 0–3.1)
Patients
Visual analog scale (VAS) (before surgery)
4.70 ± 1.68
Visual analog scale (VAS) (after surgery)
Three cases had slight paroxysmal swelling pain because of bladder spasm, but the time of bladder spasm was very short. Two cases complained of a dull ache when they left the hospital. All cases did not complain of lower pain
This study was approved by the Xiangya Hospital Central South University Research Ethics Committee (Hunan, China). Written informed consent was obtained from all patients for entry into this study after full explanation of the procedure. Our institution reported 15 cases of parapelvic renal cysts between October 2011 and May 2013. These cases were all treated by an operation using a flexible ureteroscope. A total of nine men and six women (mean age 53 years, range 42–68), with renal parapelvic cysts confirmed by computerized tomography (CT), were admitted with initial complaints of abdominal or flank pain, recurrent urinary tract infection or hematuria. The visual analog scale (VAS) was used for the assessment of variation in intensity of pain. VAS was 4.70 ± 1.68 before surgery. Patient characteristics are listed in Table 1. Two patients had previously undergone cyst aspiration, but all cases had previous unsuccessful treatments. Because of continuous abdominal or flank pain (15 cases), recurrent urinary tract infection (2 cases) or hematuria (3 cases), all patients were strongly advised to be treated surgically. Inclusion criteria for the study included: the presence of a renal parapelvic cyst, compression of the renal collecting system by the cyst and/or previous unsuccessful treatments. Exclusion criteria included: cardiopulmonary insufficiency, coagulation disorders and/or lower urinary obstruction. Flat sweep and enhanced CT scans were necessary to demonstrate renal parapelvic cysts, which compressed the renal collecting system (Fig. 1). The CT was also necessary to help distinguish among the various potential classes of abnormalities, including renal parapelvic cysts, peripheral renal cysts, hydronephrosis, renal stones and other abnormalities. The largest mean cyst size was 6.1 cm (range 4.5–7.8 cm). Patients with complex cysts, defined as the presence of more than two cysts, were excluded from the present study. Procedures All patients were given general anesthesia before surgery. A 4F guidewire was advanced transureterally to the renal
123
Location/presentation Left
9
Right
6
Renal pelvis obstruction
5
Upper pole obstruction
7
Lower pole obstruction
3
Symptoms (n) Abdominal or flank pain
15
Hematuria
3
Recurrent urinary tract infection
2
Number of patients who used ultrasound (during the operations)
6
Number of patients
N
Whose cyst size was not reduced to half of the previous size
1 case
Whose cyst size was not reduced to half of the previous size
4 cases
Whose cysts disappeared Mean total operation time
10 cases 31 ± 8 min
Mean duration of incision of the renal cyst
13 ± 2 min
Mean estimated blood loss
20 ± 5 ml
Mean hospital stay
3 days (range 2–4 days)
pelvis with the ureteroscope to guide the ureteral access sheath, which enables access to the renal pelvis through the ureter. The study was performed with an 8.5F electronic flexible ureteroscope (UFR-P3, Olympus; Tokyo, Japan) and fiber flexible ureteroscope. The first patient was treated with the fiber flexible ureteroscope, and the other patients were treated with the electronic flexible ureteroscope. Inside the ureteropelvic region, the cyst wall was generally
Int Urol Nephrol
Fig. 1 The CT shows the renal cysts before the operation, in the first postoperative month, and in the sixth postoperative month. The first picture shows renal parapelvic cysts compressing the renal collecting
system. The second picture shows cysts in the first postoperative month, and the ureteral stent is shown by the arrow. The third picture shows cysts in the sixth postoperative month
found to be compressing the collecting system and was noted to be obstructing the urinary collecting system with (or without) the guidance of B ultrasound. Direct ureteroscopic vision was used to guide a 200-lm laser fiber (0.8 W/hz, 20 Hz; FlexiFib, LisaLaser; Katlenburg-Lindau, Germany) to incise the cyst wall that was adjacent to the collecting system. The full-thickness, openincised thin area was about 2–4 cm to communicate with the collecting system. To avoid closing the cyst margins, the Ho–YAG laser was used to completely coagulate the margin of incision, covering the entire incised margin. A 5F Double-J stent, which was removed in the clinic after 4 weeks, was placed with the proximal end coiled in the cyst cavity to drain the cystic fluid [17]. To avoid misdiagnosis of cystic renal cell carcinoma, the cyst interior was completely examined and a portion of dissociative renal wall, which was incised by the Ho–YAG laser, was biopsied with the ureteroscopic biopsy. CT scans after 1, 6 and/ or 12 months showed no signs of recurrence of cysts or stones.
was controlled with solifenacin. One patient exhibited minor hematuria, but these symptoms disappeared after the third postoperative day. Average total operation times, mean duration of incision of the renal parapelvic cyst and mean estimated blood loss were 31 ± 8 min, 13 ± 2 min and 20 ± 5 ml, respectively. The mean length of hospital stay was 3 days (range 2–4 days). All pathology findings revealed benign renal cysts. Radiologic success was defined as no recurrence of the cyst or a reduction in cyst size by at least 50 %. CT scans showed that in one case, cyst size did not decrease to half of its previous size, and in four cases, cyst size was less than half of the previous size after 6 months. CT or color Doppler ultrasound showed that all cysts disappeared in the other cases after 6 or 12 months.
Results There were no intraoperative complications. Patients reported marked relief or disappearance of pain, and there was clinical observation of hematuria disappearance after the operation. No patients reported lower back pain or discomfort during the hospital stay after surgery. However, slight swelling and bladder spasm occurred in three cases in the hospital; the time of bladder spasm was very short, and two cases complained of paroxysmal pain when they were discharged from the hospital after surgery. Their pain
Discussion With the development of novel therapeutic techniques for treating renal cysts, minimally invasive (keyhole) surgical procedures [10–15] have gradually replaced open surgery [3]. Aspiration and sclerotherapy are associated with a high recurrence rate, and accidental spillage of a sclerosing agent can lead to severe peri-renal inflammation, abscess formation, fever, pain and secondary ureteropelvic junction obstruction [18–20]. Because of adhesions around the retroperitoneal area, previous renal surgery makes laparoscopic access more difficult, and obesity makes laparoscopic procedures more time-consuming due to the increased need for dissection [11, 14]. Significant complications (e.g., hemorrhage, collecting system leak and urinary fistula) may result from fulgurating the base of the
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Fig. 2 Photograph of typical cyst walls observed in patients in this study. The color of the wall is gray or chic blue, the cyst wall is without vessel pulsation or the selected cyst wall is similar to a translucent membrane
renal cysts to destroy the secretory activity of the remaining cyst wall [15, 21]. While no serious complications have been noted for percutaneous ablation with cyst resection using a resection loop for the prostate [22] or percutaneous intrarenal marsupialization of symptomatic peripelvic renal cysts [9], other procedures require longer mean operative times. Another reported technique, percutaneous resection, also exhibited no complications, but the mean operative time was 55 min, which is considerably longer than in our study (31 ± 8 min), and the technique did not show simple renal cysts [23]. Percutaneous endocystolysis [24] is another technique that has been used for resolution of renal cysts. The mean operative time is slightly longer than demonstrated in our study, but there have only been five cases reported and the incidence of cyst perforation was 12.5 % [24]. Complete transurethral translumenal endoscopic surgery has been successfully developed and includes flexible retrograde ureteroscopy [16, 17]. However, the two studies describing the procedure provided little discussion of the need to avoid injuring the renal vessels or hilar structure and recurrence of renal parapelvic cysts due to small patient numbers (i.e., only 8 cases). In the present work, we describe our initial clinical experience using the flexible ureteroscope in the management of renal parapelvic cysts. Keys to success in treating renal parapelvic cysts are to avoid injuring the renal vessels or hilar structure and minimizing cyst recurrence. The first key question to consider is how the parapelvic cyst wall can be found. First, a flat sweep and enhanced CT scans are necessary to demonstrate the presence of renal parapelvic cysts, and the CT shows whether the cysts compress the renal collecting system. Subsequently, the use of a high-definition camera system may be very
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important in finding the cyst wall. In our practice, we report on 14 cases in which the cyst wall was detected with an electronic flexible ureteroscope, because we found that the fiber flexible ureteroscope provided a dim image in those surgeries. Third, the cyst wall curves toward the collecting system and may show a circular shape. The cyst wall may compress the renal calyceal neck, altering how it is viewed in the image. Fourth, the color of the wall is gray or chic blue, or the cyst wall is without the vessel pulsation or the selected cyst wall is similar to a translucent membrane (Fig. 2). Finally, color Doppler ultrasound is valuable in helping to find the parapelvic cyst wall if we have difficulties or uncertainties with the methods described above. The second key question is how to deal with the parapelvic cyst wall. Our practice is similar to the experience reported by others [16, 17], but exhibits some important differences, as described below. The selected cyst wall is similar to a translucent membrane. In this situation, the incised cyst does not recur because the margin of incision does not produce scar tissue. Furthermore, if the size of ‘‘the translucent membrane’’ is not large enough, we increase the size of the incision around the cyst wall and completely coagulate it. Subsequently, if the incised cyst wall, which is not similar to the translucent membrane, is without vessel pulsation and the color of the wall is pale and dim, the size of the incision and the completely coagulated cyst wall in this situation should be larger than the size of the incised cyst wall in the first or second situation. The margin of incision may produce scar tissue if the incised size is not large enough, which may contribute to development of a diverticulum or may make the incised cyst wall close. Next, if we find the cyst wall does not have any differences from the collecting system under direct
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Fig. 3 Use of B ultrasound to guide surgeons to the proper site to incise the cyst wall. When the Ho–YAG laser incised the parapelvic cyst wall, hyperechogenicity occurred in the B ultrasonography (shown by the arrow)
ureteroscopic vision, the B ultrasound guides us to incise the cyst wall (Fig. 3). Subsequently, we performed electroresection and electrocautery of the incision at a lowenergy setting to avoid hemorrhage with 200-lm holmium laser fiber (0.8 W/hz, 20 Hz). In theory, the green light laser may be safer than the holmium laser [25]. However, the green light laser was in short supply in our hospital. Li and colleagues [17] reported a portion of the cyst wall was first harvested by ureteroscopic biopsy forceps for histopathology examinations. In contrast, our experience was that we send the dissociated cyst wall that was not cut by ureteroscopic biopsy forceps but was incised by Ho–YAG laser, for histopathology examination, to avoid causing hemorrhage. Next, when the cyst wall is incised, the thickness of the margin of the incised cyst wall should be observed. If the margin of the incised cyst wall is relatively thick, incision of the cyst wall should be stopped because this situation may increase the risk of bleeding. Finally, similar to Li and colleagues [17], a 5F double-pigtail ureteral stent was positioned with the proximal end coiled in the cyst cavity [17]. We consider that the double-pigtail ureteral stent not only provides for efficient drainage but can also avoid closing of the incised cyst wall. In our study, average total operation times, mean length of hospital stay and mean estimated blood loss were similar to those reported by Li and colleagues [17]. The mean duration of the incision procedure for the renal parapelvic cyst is only 13 ± 2 min. We spend more time finding the cyst wall, especially when the cyst wall does not exhibit clear differences from the collecting system. In our hospital, parapelvic cysts are treated by retroperitoneoscopic decortication by one group of physicians [15]. In this study, the mean estimated blood loss is obviously less than that for the parapelvic cysts treated by retroperitoneoscopic
decortication. Mean hospital stay was slightly less than that for the parapelvic cysts treated by retroperitoneoscopic decortication. In our study, cyst size in one case was not reduced to half of its previous size after the twelfth postoperative month. Because we found that the margin of the incised cyst wall was thick, the incision process was stopped to avoid bleeding. The full-thickness, open-incised area was\2 cm. With collapse of the cyst or healing of the cyst wall, the parapelvic cyst wall may close or the cyst may become a diverticulum, which may result in flank pain, hematuria, recurrent urinary tract infections or symptomatic stones. Minor hematuria occurred in one case but disappeared after the second postoperative day. We found that the patient’s pelvis–ureter junction had slight stricture during the operation. We assessed the reason why the patient exhibited minor hematuria and concluded that the flexible ureteroscope may have injured the ureteral mucosa because of the slightly narrow pelvis–ureter junction. Three patients felt slight swelling pain in the bladder area during their hospital stay. However, when bladder irritation did occur, the foley was withdrawn because we believe that the time of foley insertion should be as short as clinically possible. Two patients complained of paroxysmal pain. We speculated that bladder irritation symptoms occurred in these two cases in the first postoperative month and were later controlled with solifenacin. Additionally, a tortuous, kinked or angulated ureter makes the ureteroscopy procedure more difficult. For this problem, the morphology of the ureter was determined with intravenous urography (IVU) and shown to have various degrees of tortuous, kinked or angulated ureters. Therefore, IVU was conducted on the patients before the operation to view the ureter. If the patient has a tortuous, kinked or angulated ureter, we
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suggest placement of a double-J ureteral catheter before surgery. After an additional month, the patient is recommended to undergo surgery. In conclusion, we demonstrate the feasibility, safety and effectiveness of the flexible ureteroscope for retrograde treatment of renal parapelvic cysts. This was accomplished through appropriate patient selection and skilled surgeons.
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