Laparoscopic Nephrectomy for the Kidney with the History of Serious Urinary Tract Infection

Abstract

Introduction:

Laparoscopic nephrectomy is sometimes difficult because of large renal mass, vascular anomalies, or severe adhesion. Urinary tract infection usually leads wide adhesion from serious inflammatory reaction around renal parenchyma, which often involves renal vessels and adjacent organs. However, atrophic kidney occasionally must be removed in some situations. For example, repeated episodes with atrophic parenchyma or low-volume urine drainage from the nephrostomy tube placed for the treatment of pyohydronephrosis would be an inevitable reason to decide the removal of atrophic kidney. Some investigators recommend choosing indications prudently for laparoscopic surgery because of the surgical difficulties, whereas others try laparoscopic approach at first for postoperative quality of life. ^{1 –3}

Materials and Methods:

Laparoscopic nephrectomy was done to five cases of atrophic kidneys caused by serious infectious episodes. Cases are all women. Two cases were treated by antibiotics alone and three cases by antibiotics with percutaneous drainage before laparoscopic procedure. Nephrectomy was done within a couple of months after complete remission of infection.

Results and Conclusion:

Adhesion around kidneys was not predictable by preoperative evaluations, but main vessels could be divided with the identification of precise layer. Renal vein tends to keep normal size, although renal artery is usually atrophic. The difficulty of procedure would depend on the degree of inflammatory change on renal pedicle, mainly. To minimize blood loss, sealing device with cutting tip provides great help. In the worst case, renal pedicle should be incised using sealing device alone without ligation, because renal vessels could not be identified in hard tissue after infectious episode. All procedures were done without postoperative complications. Average operation time was 203 min, which was slightly longer than ordinary radical nephrectomy. Average blood loss was 47 mL. Nephrostomy placement seems not to interfere with the operation. The key point for completing the procedure seems to be the management of renal pedicle, which should be changed depending on the individual condition. Involving adjacent organs in inflammatory change may cause serious intraoperative complication. Fragile renal pelvis could be lacerated with spillage of infected material, which should be managed with complete lavage and drainage tube placement. Laparoscopic nephrectomy of atrophic kidney after serious infection may be a high-risk procedure. It could be a challenging case in worse infected kidneys such as staghorn calculi, xanthogranulomatous pyelonephritis, and emphysematous pyelonephritis, especially with active infection. However, in these days, the experienced surgeon can provide this choice for the patient at first, even only for investigating the condition of surgical field.

No competing financial interests exist.

Runtime of video: 8 min 25 sec