How safe and effective is laparoscopic decortication of simple renal cysts in elderly patients?

Abstract

Objective: To investigate the assessment of feasibility and safety of laparoscopic decortication of simple renal cysts in elderly patients.

Methods: The data of 114 patients who underwent laparoscopic decortication for simple renal cyst between October 2011 and May 2019 were retrospectively evaluated. Patients’ age, gender and ASA scores; operation time; cyst size and location; complications; hospital stays and success rates of operations were recorded.

Results: The mean age of the patients were 73.8 ± 8.2 years. Forty-eight (42.1%) of the patients were female and 66 (57.9%) were male. Cysts were localized on the right side in 61 (53.5%) patients and on the left side in 53 (46.5%) patients; and mean cyst size was 72.83 ± 31.13 mm. Also, they were localized on the anterior in 88 (77.2%) patients and on the posterior of the kidney in 26 (22.8%) patients. Preoperative ASA score distributions were ASA-I in 12 patients (10.5%), ASA-II in 31 patients (27.2%), ASA-III in 68 patients (59.7%), and ASA-IV in 3 patients (2.6%). Mean operative time was 41.4 ± 5.6 min. Clavien grade 1 complications were observed in 5 (10.4%) patients. Median hospitalization time was 1 day. No recurrence was occurred in any patient in the postoperative period.

Conclusions: Although laparoscopic surgery has some risks and complications for elderly patients, laparoscopic decortication can be applied safely and effectively in treatment of simple renal cyst in that patient population.

Keywords:

• Laparoscopy
• laparoscopic
• decortication
• renal cyst
• elderly

Introduction

Renal cysts are common kidney lesions. They are classified by Bosniak as simple (Bosniak type I and II) or complex (Bosniak type IIF and III and IV) cysts. Simple renal cysts are common benign lesion and their prevalence ranges from 7% to 10% [1,2]. They are found in at least 24% of those over 40 years of age and at least 33% by the age of 60 [3]. Most of them are detected incidentally and are peripheral in location without any symptoms. Simple renal cysts do not require intervention unless symptomatic while complex renal cysts require follow-up (Bosniak type IIF) or surgery (Bosniak type III and IV) in order to exclude malignancy. Simple renal cysts in large size (diameter >7 cm) are often symptomatic with several symptoms such as back pain, urinary tract infection, hemorrhage, pelvicalyceal obstruction, hydronephrosis, hematuria, hypertension and compression of adjacent organs [4,5]. Pain is the most common indication for intervene in simple renal cysts [6]. There are several options for the management of symptomatic simple renal cyst: medical management of pain; aspiration of cyst; transperitoneal and retroperitoneal laparoscopic decortication of cyst; robotic surgery and open surgery [7,8].

Laparoscopic decortication of simple renal cysts (LDC) has become more preferred option with high cure, low recurrence and minimal morbidity rates [7]. The advantages of laparoscopic surgery are less post-operative pain, decreased hospital length of stay, improved cosmesis, and a quicker return to daily routine. On the other hand, laparoscopic surgeries have some disadvantages such as prolonged operation duration and adverse effects of CO₂ pneumoperitoneum on circulatory and respiratory system [9]. Although most of these adverse effects do not result in clinical significance, they can suppose considerable importance in patients with comorbid conditions, particularly those that result in decreased cardiopulmonary reserve, as are common in elderly patients.

In an increasingly aging society, laparoscopic surgery is increasingly being needed for elderly patients in the field of urology. However, only limited number of studies have been conducted on laparoscopic surgery in elderly patients with urologic disease. To our knowledge, there is no report about safety and efficacy of laparoscopic renal cyst decortication in elderly patients in literature.

The aim of our study was to assess the feasibility and safety of laparoscopic decortication of simple renal cyst in elderly patients.

Materials and methods

We retrospectively reviewed the records of 114 patients over the age of 65 years who underwent LDC between October 2011 and May 2019. All laparoscopic procedures were performed by two surgeons. The local institute ethics committee approved the study and written informed consent was obtained from all patients.

Indications for intervention of all cases were flank pain. All renal cysts were diagnosed by ultrasonography and CT urography according to Bosniak classification. Patients were evaluated by serum creatinine, blood urea nitrogen level, urine analysis and coagulation profile.

In all cases, the same general anesthesia protocol was used. After induction of anesthesia, a nasogastric tube and a urinary catheter were inserted. All patients were placed in a modified [70 degree] lateral decubitus position with the umbilicus over the break of the operating table. Pneumoperitoneum was induced in all groups using a Veress needle and CO₂ was insufflated at a rate of 2 L/min until intraabdominal pressures of 10–12 mmHg was reached. Intraperitoneal insufflation at this pressure was held constant by automatic regulation of the CO₂ inflow. First, an 11 mm trocar was inserted, the abdomen was inspected by a 0°, 10 mm rigid laparoscope for any injury due to Veress needle or port placements. Then, two 5 mm trocars were inserted under direct vision. The surgical procedure was performed according to technique used in transperitoneal laparoscopic cyst decortication. The cyst wall was circumferentially excised by electrocautery or ultrasonic energy and fluid was aspirated. Specimens were retrieved through the 5 mm trocar without trocar removal and submitted for later pathologic analysis. We routinely placed a drainage tube through the lower trocar. In all cases, residual CO₂ in peritoneum was evacuated at the end of the procedure by compressing the abdomen. The operation time was calculated from the first trocar insertion to the last trocar extraction. After the laparoscopic surgery was completed, all patients were injected with 5 ml of 5 mg/mL bupivacaine at all trocar areas. All patients were routinely prescribed postoperative analgesia, with 20 mg tenoxicam administered intravenously at 6 and 18 h, postoperatively.

All patients were reassessed with clinical and ultrasonographic examinations at 1 month and 6 months. Surgical and radiologic success was defined as no a visible renal cyst on the operating area on ultrasonography.

Statistical analyses were performed by Statistical Package for Social Sciences (SPSS) software for Windows, version 15.0 (SPSS Inc., Chicago, IL). Continue variables were presented as mean ± SD if they are normally distributed. Median (IQR) was used if they are not normally distributed. Categorical variables were presented as frequencies/percentages.

Results

In total, 114 patients were included in this study, comprising 48 (42.1%) female and 66 (57.9%) male with a mean age of 73.8 ± 8.2 years. Twenty-one (18.4%) of the patients had at least 1 previous unsuccessful cyst aspiration. Preoperative ASA score distributions were ASA-I in 12 patients (10.5%), ASA-II in 31 patients (27.2%), ASA-III in 68 patients (59.7%), and ASA-IV in 3 patients (2.6%). Simple renal cysts were localized on the right side in 61 (53.5%) patients and on the left side in 53 (46.5%) patients and mean cyst size was 72.83 ± 31.13 mm. Also, they were localized on the anterior in 88 (77.2%) patients and on the posterior of the kidney in 26 (22.8%) patients. Mean operative time was 43.4 ± 4.8 min. The characteristics of the patients are listed in Table 1. No intraoperative complications were recorded. Blood loss in all patients was minimal and could not be measured. Clavien grade 1 complications such as fever and delayed bowel movement were occurred in 8 (7%) patients. These patients were treated with antipyretic medications and/or intravenous hydration. No complication was observed during and after the operation in any of the 21 patients who had a history of renal cyst aspiration. Drainage tubes were removed on the first postoperative day except 3 patients with prolonged drainage. Median hospitalization time was 1 day (range 1–3 days). Pathological examinations of specimens were benign character in all cases. At 1- and 6-month follow-up, all patients were asymptomatic and no radiological recurrence was detected in any patients. Of the patients, 14 did not have 6-month follow-up.

Table 1. Patients characteristics, operative and postoperative data.

	N:114
Age (years)	73.8 ± 8.2
Gender (male/female), n (%)	66 (57.9%)/48 (42.1%)
Cyst size (mean ± SD), mm	72.83 ± 31.13
Location of cyst, n (%)
Right	61 (53.5%)
Left	53 (46.5%)
Anterior	88 (77.2%)
Posterior	26 (22.8%)
Previous unsuccessful aspiration, n (%)	21 (18.4 %)
ASA scores, n (%)
ASA I	12 (10.5%)
ASA II	31 (27.2%)
ASA III	68 (59.7%)
ASA IV	3 (2.6%)
Operation time (mean ± SD), min	43.4 ± 4.8
Clavian grade I complication, n (%)	8 (7%)
Discharge time, median (IQR)	1 (1–3)
1st postoperative day, n (%)	104 (91.2%)
2nd postoperative day, n (%)	7 (6.2%)
3rd postoperative day, n (%)	3 (2.6%)
Success rate
1st postoperative month, %	%100
6th postoperative month, %	%100^a

The data were given as n (%), mean ± standard deviation.

^aOf the patients, 14 did not have 6-month follow-up.

Discussion

In 2019, there were 703 million people aged 65 years and older [10]. According to the WHO, it is expected to reach over 1.5 billion people in 2050 [10]. Elderly population represent a large proportion of the candidate patients for any surgery, and the surgical need of this population is increasing. Conventionally, elderly patients have been treated with a less aggressive approach because of their comorbidities and higher surgical risk. In general patient population, laparoscopic surgeries have become more common with decreased blood loss, less postoperative pain, reduced length of hospital stay, improved mobilization, quicker return to normal activity and less abdominal wall complications. It has been discussed as to whether elderly patients can gain the same benefits from laparoscopic surgery. The concern in this population is that physiologic requirements may surpass the benefit seen in younger patients. This concern cause by situations related to longer operative times, increased technical challenge, physiologic effects of CO₂ pneumoperitoneum and patient position during laparoscopy [11,12]. CO₂ insufflation during laparoscopy can cause acid–base imbalance, changes in blood gas balance, and changes of cardiovascular and pulmonary physiology [13]. While most of these effects do not result in clinical significance, they can assume considerable importance in patients with comorbid conditions, especially those that result in decreased cardiopulmonary capacity, as are common in elderly patients [14].

Currently, the two most preferred options for the treatment of symptomatic simple renal cyst are aspiration (with or without a sclerosing agent) and laparoscopic decortication of cyst. Among clinicians, there is a tendency in favor of aspiration in the treatment of simple renal cyst in elderly patients. A high recurrence rate and loss of renal function caused by the unplanned leakage of sclerosing agent into the collecting system are major harmful effects of aspiration of cyst [15]. Aspiration of cyst is easier to perform in cortical renal cysts but it has a high recurrence rate with variable reports between 41 and 100% [6]. However, recurrence rates of aspiration with sclerosing agent also seem to be high with 30–54% reported [16,17]. Moreover, aspiration is technically challenging in parapelvic cysts because of their proximity to renal hilum. The recurrence rates have been reported to be between 0% and 15% based on the procedure adopted for LDC (transperitoneal and retroperitoneal) [6]. Retroperitoneal approach is accepted as an easier method in cysts located in the posterior of the kidney. The main advantage of this approach is that the risk of intraperitoneal organ injury is low and retroperitoneum has a limiting role for complications such as bleeding or urinoma. Main disadvantages of this approach are a narrower working area and difficulty in mobilizing the kidney for large cysts. In their study, Huri et al. did not find a significant difference between transperitoneal and retroperitoneal approaches in terms of success rate and recurrence [18]. Our study has demonstrated that the recurrence rates after transperitoneal laparoscopic renal cyst decortication in the elderly patients are consistent with the literature. Considering that most of the cysts were anterior located, it can be seen that the mean duration of the surgeries was relatively short in our study. In healthcare centers that have an adequate amount of laparoscopic surgery experience, performing laparoscopic decortication of renal cyst provides a significant advantage in terms of radiological and symptomatic success in elderly patients. The majority of the elderly population are high-risk patients (ASA3 and ASA4). An increase in the rate of intraoperative and postoperative complications is expected in these patients. Although the majority of patients included in the present study were high-risk patients, no major perioperative or postoperative complications were observed in any patients. According to the modified Clavien classification, eight patients were reported to be grade 1. The present study demonstrated that laparoscopic renal cyst decortication can be applied effectively and safely in elderly patients who had a history of renal cyst aspiration, too. As anticipated, the duration of hospital stays reported for laparoscopic renal cyst decortication was longer than that reported for aspiration of cyst but rather shorter than that reported for open surgery. Median hospitalization time was 1 day in our study.

Procedures involving pelvic anatomy such as urachus, bladder and prostate surgery necessitate that the patient is in the Trendelenburg position which will affect cerebrovascular, respiratory and hemodynamic homeostasis [19,20]. It has been reported that the complications of laparoscopic pelvic surgery seem to be more than those of laparoscopic nonpelvic surgery in elderly patients [21]. Furthermore, prolonged operation time of these laparoscopic surgical procedures also may increase the complication rates. In the laparoscopic renal cyst decortication, complication rates may be lower due to the short operation time and, not requiring a special surgical position such as the Trendelenburg position. Most of the laparoscopic urological surgeries have a steep learning curve, which may lead to an increase in complication rates. However, LDC has a relatively easier learning curve, which may be associated with fewer complications.

Increased intraabdominal pressure may cause changes in hemodynamic function that may disrupt cardiac function and the perfusion of vital organs. Increased pressure on intra-abdominal organs has been shown to decrease vascular perfusion, which has been shown to decrease renal and hepatic function [22,23]. “The higher the pressure, the better the view” is the motto among laparoscopists. Besides, it may be necessary to increase intraabdominal pressure in case of bleeding in the major laparoscopic surgeries. It should be kept in mind that the higher the intraabdominal pressure the more problems arise. According to the recommendation of the European Association for Endoscopic Surgery, a rational approach could be to employ minimum pneumoperitoneum pressure that allows adequate exposure of the surgical field [24]. Since bleeding is not an expected condition in laparoscopic management of simple renal cyst, increasing intraabdominal pressure is not an expected condition, too. We performed LDC operations by 10–12 mmHg pressure without the need to increase the intraabdominal pressure in all cases.

Retrospective design and small number of the patients are the most important limitations of the study. The other limitation of the study is that 14 patients had only the first month follow-up in terms of recurrence. However, it is the strength of our study to be the initial study on laparoscopic decortication of simple renal cyst in the elderly patient population.

Conclusions

Although laparoscopic surgery, which is used extensively in all urological surgeries, has some risks and complications for elderly patients in major and long operations, it can be applied safely and effectively in treatment of simple renal cysts in those patients. Perhaps, simple renal cysts are the most appropriate cases among laparoscopic urologic surgeries, with short operation duration and low complication rates, in elderly patients.

Author contributions

A.A., C.A. contributed in study design, manuscript preparation, data collection and analysis, drafting and revising of manuscript, review and final approval of manuscript.

Disclosure statement

No potential conflict of interest was reported by the author(s).