Introduction

Renal cysts are common benign lesions of the kidney estimated to occur in at least 24% of individuals older than 40 years and 50% of individuals older than 50 years, who are evaluated by abdominal computed tomography for nonurologic indications (1). With the recent widespread and increase use of abdominal cross-sectional radiographic imaging, the incidence of asymptomatic renal cysts is likely higher than previous estimates. Although renal cyst may be congenital or acquired, most are simple, asymptomatic, and of unknown etiology. However, some patients develop abdominal and/or flank pain, hematuria, hypertension, recurrent infection, or obstructive uropathy as a result of a renal cyst (2).

Open surgical exploration and treatment of renal cysts have been reported since the early 1900s. One of the earliest formal reviews of the literature and descriptions of open surgical management of renal cysts was performed by Kretschmer in 1920 (3). Of 35 patients who were explored through flank or abdominal incisions, 18 underwent excision or resection of a renal cyst, 16 required nephrectomy, and in one patient the cyst was marsupialized. He concluded that surgical resection of the cyst should be performed when possible. Open renal cyst ablation, although effective, was not without morbidity. In 1967, Kropp et al. reported a 37% complication rate in 126 patients undergoing open renal exploration for cyst, including two patients dying in the postoperative period (4). Because the surgical treatment of a benign condition such as a renal cyst did not generally require organ extirpation but rather only excision of the cyst wall and evacuation of its fluid contents, less invasive means of treating symptomatic renal cysts without requiring a large flank or abdominal incision were searched. Open renal cyst ablation remained the gold-standard approach until the late 1980s when minimally invasive methods were introduced.

In 1989, Holmberg and Hietala described percutaneous puncture and drainage of peripheral renal cysts under local anesthesia followed by instillation of bismuth-phosphate sclerosant (5). Although short-term success was high, limitations of this technique included a high cyst recurrence rate (54%) and the risk of collecting system strictures as a result of scarring caused by the sclerosing agent, making this technique ill advised for cysts located in the peripelvic region. Percutaneous resection and fulguration was proposed to address symptomatic renal cysts not amenable to aspiration and sclerosis (6). However, this technique required high technical skill, a large nephrostomy tract with the need for multiple tracts to treat multiple renal cysts, the placement of a ureteral stent and was associated with the risk of electrolyte disturbances secondary to irrigant absorption. Finally, retrograde endoscopic marsupialization of renal cysts using a flexible ureteroscope was described. Limitations of this technique included technical difficulty, a secondary procedure required to remove an indwelling ureteral stent, and its indications restricted to the treatment of peripelvic cysts only (7). Although each of these three minimally invasive approaches was effective for selected unilateral cysts, none provided the ability to easily address all types of cysts or complex cysts (multiple, bilateral, and/or peripelvic cysts) in one setting.

Hulbert and coworkers presented the first description of The advantage laparoscopic decortication of symptomatic renal cysts in 1992 (8) this technique included the ability to address multiple, peripelvic, and bilateral renal cysts in a single operation, while minimizing incisional morbidity.

Since its description, both transperitoneal and retroperitoneal laparoscopic approaches have been evaluated with excellent success rates (9-16).

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