F16(Th)
REMOVAL OF MASSIVE POLYCYSTIC KIDNEYS BY MINIMALLY INVASIVE
SURGERY: A CASE REPORT
¹de Takats, D, Golash, A²
¹Nephrology Department,
Staffordshire
2
Urology
Department,
University
Hospital
of
North
PROBLEM: Large polycystic kidneys can be asymptomatic or may present a range of
problems which tip the balance of risk and benefit in favour of nephrectomy. When bilateral
nephrectomy is undertaken by open nephrectomy this is major traumatic trans-abdominal
surgery involving a large incision of either the ‘rooftop’ subcostal type or a long midline
incision (xiphisternum to pubis) with all the attendant consequences in terms of wound healing
time and possible complications associated with such large incisions such as prolonged time
course for wound healing, increased infection risk and incisional hernias.
PURPOSE: We wished to reduce the risk of such events and offered minimally invasive
surgery to a patient with enormous polycystic kidneys relative to his size as an innovative
option pushing at the boundaries of surgical experience.
CASE: A56 year old man with Autosomal Dominant Kidney Disease (ADPCKD) in full time
employment had been started on haemodialysis using a previously prepared arterio-venous
fistula when he reached End-Stage Renal Failure in January 2010. The only complications he
had suffered in from his kidneys were due to their size; he had not had urinary tract infections.
These complications were due to the limited space left by his kidneys in his abdomen to
accommodate his gastrointestinal tract: this manifested essentially as reduced appetite and
nutritional compromise due to early satiety due to gastric compression and slow transit time.
This was overcome by the ‘little and often’ approach mostly using dietary supplement drinks
and puddings. The other point of note is that his physique was markedly distorted by his
kidneys giving him a late pregnant appearance. The reason for proceeding to nephrectomies
was that the lower poles of both kidneys extended into the pelvis leaving no room to place a
kidney transplant in a gentleman who would otherwise be fit for this option. Removing both
kidneys was chosen to minimise the risks and his recovery time and so as not to leave him
asymmetrically distorted.
SURGERY and POST-OPERATIVE COURSE: Surgery took placein July 2010 over the
course of a full day. The kidneys were removed piecemeal macerated using 8 minimal incisions
including those for instrumental access. The patient’s post-operative stay in hospital was 13
days. The only immediate complication was a period of ileus. Subsequently he has done well,
given up smoking, returned to work and taken up gym exercise, keen to retain his new slimmer
figure in the face of a much improved ability to eat without early satiety. The only other
complication has been intestinal hurry, for which no sinister cause has been found on
investigation, now settling. Pre-operative dry weight: 70.5 Kg, immediate post operative
weight: 57.5 Kg, current dry weight: 60.5 Kg. He is now a fit candidate for kidney
transplantation.
It is intended to illustrate the case with scan images demonstrating the extent of the filling of the
abdominal cavity by the polycystic kidneys and with ‘Before’ and ‘After’ photographs of the
patient.
CONCLUSION: This case report is proof of principle that minimally invasive surgery can be
safely and effectively undertaken for removal of polycystic kidneys in ADPCKD even when the
kidneys are very large both in absolute terms and in relation to the size of the abdominal cavity
they lie within.