Indications and Contraindications

Laparoscopic renal cyst ablation is indicated in patients with symptomatic, simple renal cysts, who have failed medical management (i.e., analgesics, nonsteroidal anti-inflammatory agents, narcotics, etc.). An initial attempt at percutaneous drainage with or without sclerosis should be performed prior to laparoscopic exploration and ablation.

Because of the high incidence of cyst recurrence following simple percutaneous drainage, multiple sclerosing agents have been proposed, including the use of alcohol, tetracycline, minocycline, or povodine-iodine with variable success (5,19,20). These sclerosing agents should, however, be avoided in parapelvic cysts as scarring and strictures of the collecting system have been reported (5).

Assessing change in symptoms following the reduction of cyst volume: initial percutaneous aspiration of the renal cyst(s) also determines which patients are more likely to gain benefit from laparoscopic ablation if the cyst and symptoms recur (11).

A suggested treatment algorithm for managing symptomatic peripheral and peripelvic renal cysts is shown in Figure 4.

Patients with complex renal cystic disease such as autosomal dominant polycystic kidney disease, von Hippel-Lindau, acquired renal cystic disease, or tuberous sclerosis have a predisposition to malignancy. In addition, patients with autosomal dominant polycystic kidney disease frequently have flank/abdominal pain or worsening hypertension associated with enlargement of their renal cysts. Laparoscopy is an effective means of treating autosomal dominant polycystic kidney disease patients who suffer from painful renal cysts and evaluating indeterminate (Bosniak class Il and III) renal cysts (21-24).

Laparoscopic renal cyst ablation is contraindicated in patients with uncor-rectable bleeding diatheses and those with comorbid medical conditions that preclude general anesthesia.

Prior abdominal surgery is not an absolute contraindication, but rather the site of prior surgery may alter the route of laparoscopic access (transperitoneal vs. retroperi-toneal) that is chosen.

Even in patients with a history of extensive prior abdominal surgery, a retroperitoneal access may be preferred as entry into and dissection within the peritoneal cavity is not necessary. Although extreme obesity may make transperitoneal

FIGURE4 ■ Treatment algorithm for symptomatic simple peripheral and peripelvic renal cysts.

FIGURE4 ■ Treatment algorithm for symptomatic simple peripheral and peripelvic renal cysts.

Ruptured Ovarian Cyst

Laparoscopic renal cyst ablation should not be performed in the setting of an active urinary tract infection, pyelonephritis, or renal abscess.

access more difficult, often a retroperitoneal approach is still feasible because patients typically have relatively less fat along their retroperitoneum. Unlike with Bosniak class II or III (i.e., indeterminate lesions), Bosniak IV lesions (i.e., renal cystic lesion found radiographically to be highly suspicious for malignancy) should not be approached by laparoscopic ablation, but rather by laparoscopic or open, partial, or radical nephrectomy.

Laparoscopic renal cyst ablation should not be performed in the setting of an active urinary tract infection, pyelonephritis, or renal abscess.

Special attention must be made to confirm the presence of a normal contralateral renal unit especially in cases where partial or radical nephrectomy may be required.

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