Introduction

Renal cysts are a very common condition that can occur in anyone from newborns to the elderly. Their incidence from birth to 18 years ranges from 0.1% to 0.45%, with an average incidence of 0.22%¹. In adults, their incidence gradually increases with age, and by age 40, is about 20%, while at age 60, it rises to 33%². As the majority of renal cysts are asymptomatic, they are often incidentally discovered. However, some renal cysts can cause symptoms such as flank pain (which is the most frequent complaint), palpable lumps in the abdomen, hematuria, hypertension, or urinary tract obstruction^3-5. Diagnosis is made with ultrasound, computed tomographic (CT) scans, or urography.

Renal cysts were classified using morphological characteristics by Bosniak in 1986⁶. Simple cysts are classified as Bosniak category I, which are smooth-walled, without calcification, septation, or enhancement after contrast studies. They have a very low risk of becoming malignant. Treatment of symptomatic large simple cysts is mandatory because they may produce mechanical effects of a space-occupying lesion and also have a higher risk of rupture.

The use of laparoscopic surgery to treat renal cysts was first proposed by Hulbert et al. in 1989⁷. It combines a high success rate of open surgery with low invasiveness and has thus gained wide acceptance.

Laparoscopic surgery typically uses three to six ports for a given procedure, with each port increasing the potential morbidity from bleeding, port-site hernia, internal organ damage and decreasing the cosmetic outcome^8,9. As a result of the risks associated with additional ports, a surge of interest has arisen in less-invasive alternatives.

Attempts to perform urologic surgery through a single incision began with a report by Hirano et al. ¹⁰ in 2005. Here we report a case of simple renal cyst treated successfully by a totally trans-umbilical laparoscopic de-roofing with our “Najran technique”.

Case report

A 54-year-old lady presented with right loin pain and with no urinary symptoms. Laboratory work-up showed normal values. US, CT (fig. 1) and IVU showed an about 8 x 7cm smooth-walled simple cyst of the lower pole of the right kidney with splaying of the pelvi-calyceal system, mild rotation and renal ptosis.

Figure 1

Figure 1: CT showing a right renal cyst

The patient was treated by totally trans-umbilical trans-peritoneal laparoscopic de-roofing using our technique:

Pneumoperitoneum created through an infra-umbilical incision using a Veres needle (fig. 2).

Figure 2

Figure 2: Pneumoperitoneum by trans-umbilical Veres needle

Two 5mm ports were used, one supra-umbilical and other infra-umbilical (fig. 3).

Figure 3

Figure 3: Two 5mm trocars through the umbilicus

Laparoscopic exploration revealed a large renal cyst at the lower pole of the right kidney (fig. 4).

Figure 4

Figure 4: The cyst has been surgically exposed

The cyst wall was suspended by three per-cutaneous sutures, the contents of cyst were percutaneously aspirated with a large-bore needle revealing clear fluid (fig. 5, 6) and the cyst was de-roofed with excision of part of the cyst wall using a harmonic scalpel (fig. 7).

Figure 5

Figure 5: Aspiration of cyst fluid

Figure 6

Figure 6: The cyst open

Figure 7

Figure 7: Part of cyst wall removed after de-roofing

No leak was found (confirmed by retrograde pyelogram). The wounds at the end of the operation are shown in figure 8. Operating time was 53 minutes.

Figure 8

Figure 8: Trans-umbilical incisions at the end of the operation (two with 5mm)

The patient was mobilized and started oral intake on the same operation day and was discharged on the following day in a good general condition. Cytology of the cyst fluid was negative for malignancy. Histo-pathological examination of the cyst wall revealed an inflammatory simple renal cyst and no malignancy. The patient was reviewed after two weeks in the outpatient clinic and she was doing well.

Discussion

Management of renal cysts includes percutaneous aspiration with or without sclerotherapy and un-roofing by either open surgery or laparoscopy¹¹. Open surgery is now rare because of its invasiveness, and the concomitant risks and complications. Simple cyst aspiration for diagnosis and treatment results in cyst recurrence in 50%-80% of cases¹². Percutaneous aspiration and instillation of various kinds of sclerosing agents have been used but because of higher recurrence rates (20%-50%) they are no more favored^12-14.

Laparoscopic un-roofing is an attractive minimally invasive alternative^15,16. The advantages include minimal postoperative pain and blood loss, a short hospital stay, and early convalescence. However, disadvantages of laparoscopic un-roofing include longer operation times, expensive equipment, and significant technical demands. In addition, strict criteria must be used in selecting patients for laparoscopic un-roofing to reduce the incidence of unsuspected malignancy. Only lesions that clearly meet the ultrasound or CT criteria for simple cysts should be approached laparoscopically. When a symptomatic large simple renal cyst (with a diameter >8cm) is diagnosed and definitive treatment of a cyst is indicated, laparoscopic un-roofing of the cyst is a more effective treatment than sclerotherapy.

Improvements in technology and refinement of technique have allowed urologists to perform a wide variety of complex procedures with laparoscopy, ranging from treatment of malignancy to reconstructive surgery^17-19. With the advent of urologic laparoscopy in the 1990s, urologists have effectively changed procedures that once used one large incision to procedures that now use several small incisions.

Traditionally, multiple ports are a key prerequisite for laparoscopic surgery to allow optimal instrument triangulation. Due to the widespread acceptance of standard multiple-port laparoscopic surgery, currently ongoing efforts are focused on developing strategies to further reduce incisional morbidity with improved cosmetic outcomes as a secondary benefit.

The concept of scar-free, pain-free surgery has been a long-standing surgical fantasy, a chimera. Natural orifice trans-luminal endoscopic surgery (NOTES), a recent innovation, implies intra-abdominal surgery via natural orifices (vagina, mouth/stomach, and rectum). In a similar manner, the umbilicus is an embryonic (E) natural orifice which, since it is a scar itself, conceals the intra-abdominal entry point for surgical procedures²⁰.

Attempts to perform urologic surgery through a single incision began with a report by Hirano et al. ¹⁰ in 2005. Here we report, to our knowledge, the first case of simple renal cyst treated successfully by a totally trans-umbilical laparoscopic de-roofing with our new technique which proved to be safe and effective with the advantages of short operating time, immediate postoperative symptomatic relief and a short convalescence period.

Conclusion

Totally trans-umbilical laparoscopic de-roofing with “Najran technique” is a safe and effective method to treat symptomatic renal cysts, with immediate postoperative symptomatic relief and a short convalescence period.