4. What is the role of bilateral nephrectomy in the pre-transplant work up with special reference to the image below? This patient gave a history of right flank pain which responded well to analgesia and one episode one episode of UTI responded well to antibiotic
The best answer
Thank you for your reply; both the left and bilateral nephrectomy are correct. Those suggested bilateral nephrectomy based on symptoms on the right side, a large cyst with active bleeding on the left side, and 2 small cysts on the right side with active bleeding. On the other hand, left nephrectomy alone is also correct since the symptoms are not severe on the right side, and there is an obvious advantage from unilateral nephrectomy is also correct since conservative treatment for the right side is a valid option. Removing the right kidney alone (unilateral nephrectomy) is the wrong answer.
I disagree with colleagues who suggested simultaneous bilateral nephrectomy and transplantation. It would be an ultra major operation.
The reward is Kidney Transplantation – Principles and Practice-Elsevier (2019); please contact me if you are a winner to get your reward.
Please email me at help@asnrt-edu.com
My approach is going to be similar:
Left laparoscopic nephrectomy first will be my choice in this index case. In the next few weeks or months, if the right kidney becomes more troublesome, then I would use the same incision (as used for the left) for removal (deliver) of the right kidney after laparoscopic dissection and vascular disconnection.
Dear All (Scenario 4)
Please look at the CT image (arterial phase contrast CT), read the scenario carefully, and answer the following question: Will you do unilateral nephrectomy or bilateral nephrectomy in this case and why?
We all agreed that unilateral nephrectomy has an advantage over bilateral nephrectomy.
There is a reward for the best answer
Dear colleagues,
Please read my comments in relation to bilateral vs unilateral nephrectomy for PCK in the tread of scenario no 3 (week 2) and look at the radiology picture on this index case. It is perfectly fine if you take the help of your radiology colleague in your hospital.
Ajay
Good evening,
here is my shot at the prize,
I would go for bilateral native nephrectomy.
The need for nephrectomy in this pt is discussed and agreed upon by almost all of the colleagues. I have stated (in a previous comment) the advantages of unilateral over bilateral native nephrectomy.Having said that, and considering that the pt had RIGHT flank pain while the largest hemorrhagic cysts (among many bilaterally) is in the LEFT, this pt requires bilateral nephrectomy. Both native kidneys are problematic and neither can be -confidently- left behind to the possibility of resolution post transplant.
interested to learn your opinion.
Regarding the timing and approach: i would suggest laparoscopic bilateral nephrectmy (not an easy choice as it may sound as the technical difficulty is an added burden to the high perioperative morbity) . The pt should have a dialysis axis (if still not on dialysis) and the donor workup should be completed. The plan is to go for transplant around 4-6 weeks post nephrectomy. Some surgeons may choose to do it earlier depending on the pt recovery coarse. I would not suggest similtaneous nephrectomy and transplant, although feasible, as it poses (even if passed smoothly) an extra stress on the new kidney.
Ismail, Hazem R.; Flechner, Stuart M.; Kaouk, Jihad H.; Derweesh, Ithaar H.; Gill, Inderbir S.; Modlin, Charles; Goldfarb, David; Novick, Andrew C.. Simultaneous vs. Sequential Laparoscopic Bilateral Native Nephrectomy and Renal Transplantation. Transplantation: October 27, 2005 – Volume 80 – Issue 8 – p 1124-1127
doi: 10.1097/01.tp.0000179109.51593.87
Skauby, Morten Heier1; Øyen, Ole1; Hartman, Anders2; Leivestad, Torbjørn2; Wadström, Jonas3,4. Kidney Transplantation With and Without Simultaneous Bilateral Native Nephrectomy in Patients With Polycystic Kidney Disease: A Comparative Retrospective Study. Transplantation Journal: August 27, 2012 – Volume 94 – Issue 4 – p 383-388
doi: 10.1097/TP.0b013e31825812b9
Martin AD, Mekeel KL, Castle EP, Vaish SS, Martin GL, Moss AA, Mulligan DC, Heilman RL, Reddy KS, Andrews PE. Laparoscopic bilateral native nephrectomies with simultaneous kidney transplantation. BJU international. 2012 Dec;110(11c):E1003-7.
Well done, you are a winner
Thank you for your reply; both the left and bilateral nephrectomy are correct. Those suggested bilateral nephrectomy based on symptoms on the right side, a large cyst with active bleeding on the left side, and 2 small cysts on the right side with active bleeding. On the other hand, left nephrectomy alone is also correct since the symptoms are not severe on the right side, and there is an obvious advantage from unilateral nephrectomy is also correct since conservative treatment for the right side is a valid option. Removing the right kidney alone (unilateral nephrectomy) is the wrong answer.
Well done, you are a winner
Thank you for your reply; both the left and bilateral nephrectomy are correct. Those suggested bilateral nephrectomy based on symptoms on the right side, a large cyst with active bleeding on the left side, and 2 small cysts on the right side with active bleeding. On the other hand, left nephrectomy alone is also correct since the symptoms are not severe on the right side, and there is an obvious advantage from unilateral nephrectomy is also correct since conservative treatment for the right side is a valid option. Removing the right kidney alone (unilateral nephrectomy) is the wrong answer.
Thank prof for clear explanation
I think that we can proceed with unilateral nephrectomy for the advantages explained clearly by my colleagues. Nevertheless, the presented image will help me to suggest choosing the left native kidney for the nephrectomy due to the large haemorrhagic cyst (i.e. the presented image will help to decide which kidney to remove rather than the decision of unilateral or bilateral nephrectomy).
Well done, you are a winner
Thank you for your reply; both the left and bilateral nephrectomy are correct. Those suggested bilateral nephrectomy based on symptoms on the right side, a large cyst with active bleeding on the left side, and 2 small cysts on the right side with active bleeding. On the other hand, left nephrectomy alone is also correct since the symptoms are not severe on the right side, and there is an obvious advantage from unilateral nephrectomy is also correct since conservative treatment for the right side is a valid option. Removing the right kidney alone (unilateral nephrectomy) is the wrong answer.
Pre-transplant nephrectomy should be avoided whenever possible in patients with PCKD, since it is associated with complications and also renal transplantation is associated with possible regression in the size of the kidney with time
But sometimes it is mandatory to remove either one or both kidneys before transplantation
Indications for pre-transplant nephrectomy (unilateral or bilateral)
1- Suspicion of malignancy (remove the suspected kidney)
2- Large kidney size extending below the iliac crest that extends to the site of potential transplant kidney (indication for unilateral nephrectomy)
3- Symptomatic
In the current case, I will go for bilateral nephrectomy since both kidneys are hugely enlarged, most probably will be associated with increased intra-abdominal pressure which will increase post-operative complications, also it is complicated by bilateral hemorrhagic cysts. Moreover, huge kidneys are usually associated with limitation of activity and malnutrition. Lastly, malignancy cannot be ruled out in cases of massive nephromegaly with high probability of malignant transformation after initiation of immunosuppression
Very good reasoning but what about the timing in this case with potentially complicated one alongside with the oversized.
I may recommend removal of the complicated kidney before transplantation and after healing ensured , i will go for transplantation and removal of the other kidney after transplanting the graft at the same session since there will be a space for the graft
This is because removal of both kidneys together with transplantation will be hazardous, time consuming, associated with more bleeding , hemodynamic instability due to loss of RAS system
So in order :
We remove the complicated kidney, then 1-2 months later trasplant the graft then remove the other kidney at the same session
Iagree
Well done, you are a winner
Thank you for your reply; both the left and bilateral nephrectomy are correct. Those suggested bilateral nephrectomy based on symptoms on the right side, a large cyst with active bleeding on the left side, and 2 small cysts on the right side with active bleeding. On the other hand, left nephrectomy alone is also correct since the symptoms are not severe on the right side, and there is an obvious advantage from unilateral nephrectomy is also correct since conservative treatment for the right side is a valid option. Removing the right kidney alone (unilateral nephrectomy) is the wrong answer.
regarding this case with bilateral huge kidney reaching below the iliac crest with many haemorraghic cysts , I chose to do sequential NN by removing the most bad one with infection and Hge and wait for 6wks to 3 months then do ipsilateral nephrectomy and transplantation after that , so avoid the effect of bilateral renal loss such as Unuria , anemia and hypotension, and get rid from the future problems post transplantation if the huge polycystic kidney with heamorrahgic cysts and infection remain especially with the immunosuppressant medication .
Thank you Prof. Ahmad.
as i mentioned in my detailed answer before in this case inspite of the high morbidity, mortality, and the need for blood transfusion [1], it is better to do elective open bilateral nephrectomy 2 months before the transplant or concurrently[2].
Well done, you are a winner
Thank you for your reply; both the left and bilateral nephrectomy are correct. Those suggested bilateral nephrectomy based on symptoms on the right side, a large cyst with active bleeding on the left side, and 2 small cysts on the right side with active bleeding. On the other hand, left nephrectomy alone is also correct since the symptoms are not severe on the right side, and there is an obvious advantage from unilateral nephrectomy is also correct since conservative treatment for the right side is a valid option. Removing the right kidney alone (unilateral nephrectomy) is the wrong answer.
I will proceed to unilateral nephrectomy :
*Sanfilippo et a , reported that bilateral native nephrectomy would lead to severe anaemia and mortality secondary to chronic graft failure.(1)
An anephric patient on dialysis associated with serious complications as anaemia, congestive cardiac failure, hyperkalaemia and osteodystrophy, in addition to that any residual renal function would be removed after bilateral native nephrectomy.(2)
The current consensus is that pre-transplant native nephrectomy, especially bilateral, for APKD confers no additional benefits and should not be performed.(3)
Cystic haemorrhage, recurrent UTIs/pyelonephritis, nephrolithiasis, refractory pain and enlarged kidneys which require removal for unilateral kidney transplantation are indications for simple nephrectomy in APKD patients.
Synchronous nephrectomy decreases operation time and the need for two separate operations. It was documented that synchronous unilateral/bilateral nephrectomy for SKT in APKD is safe in terms of postoperative patient morbidity and graft function.(4)
Synchronous nephrectomy with unilateral DKT is feasible. We demonstrated this successfully in our patient with ESRF secondary to APKD and with no operative/postoperative complications except for benign DGF, which resolved uneventfully.
However, at least a five-year follow-up is required to document the three- and five-year graft/host survival rates and more operations to demonstrate our method as an alternative to synchronous nephrectomy with SKT.
Our operative procedure and technique for DKT can potentially be a solution to renal vascular thrombosis secondary to kinking of donor renal vasculature, allowing APKD patients to reap the benefits of unilateral DKT, while reducing their risk of graft failure.
References:
1.Sanfilippo FP, Vaughn WK, Peters TG, Bollinger RR, Spees EK. Transplantation for polycystic kidney disease. Transplantation 1983; 36:54-9.
2.Calman KC, Bell PR, Briggs JD, et al. Bilateral nephrectomy prior to renal transplantation. Br J Surg 1976; 63:512-6.
3.Fuller TF, Brennan TV, Feng S, et al. End stage polycystic kidney disease: indications and timing of native nephrectomy relative to kidney transplantation. J Urol 2005; 174:2284-8.
4.Wagner MD, Prather JC, Barry JM. Selective, concurrent bilateral nephrectomies at renal transplantation for autosomal dominant polycystic kidney disease. J Urol 2007; 177:2250-4.
Well done, you are a winner
Thank you for your reply; both the left and bilateral nephrectomy are correct. Those suggested bilateral nephrectomy based on symptoms on the right side, a large cyst with active bleeding on the left side, and 2 small cysts on the right side with active bleeding. On the other hand, left nephrectomy alone is also correct since the symptoms are not severe on the right side, and there is an obvious advantage from unilateral nephrectomy is also correct since conservative treatment for the right side is a valid option. Removing the right kidney alone (unilateral nephrectomy) is the wrong answer.
laparoscopically left side nephrectomy is the best first step of management
Because of a large hemorrhagic cyst in the left kidney that may complicate later and cause a life threatening hemorrhage
this large hemorrhagic cyst may due to previous cyst infection
on the other had the right flank pain was tolerable and there are only small small hemorrhagic cysts
this patient need a close monitoring and may undergo a laparoscopically right side nephrectomy using the same scare if severe flank pain episodes or recurrent hemorrhage or infection progress later
Well done, you are a winner
Thank you for your reply; both the left and bilateral nephrectomy are correct. Those suggested bilateral nephrectomy based on symptoms on the right side, a large cyst with active bleeding on the left side, and 2 small cysts on the right side with active bleeding. On the other hand, left nephrectomy alone is also correct since the symptoms are not severe on the right side, and there is an obvious advantage from unilateral nephrectomy is also correct since conservative treatment for the right side is a valid option. Removing the right kidney alone (unilateral nephrectomy) is the wrong answer.
According to the CT scan view, the masses are huge and are below the iliac rest, so there is a %100 indication of nephrectomy. Unilateral may be theoretically enough, but bilateral would be better mainly because:
the other kidney with multiple cysts will confer with our follow-up, pain, hematuria, cyst infection and even malignancy
in addition, we may face surgical issues
planning which kidney will be transplanted to which side depends on the length of the vessels of the donated kidney and the anatomy of the recipient.
************
In addition, back to the original scenario, we can not expect which kidney will cause problem more. The left side may bother us. we can not use many analgesics in patients on multiple nephrotoxic drugs, and we can not afford sepsis risk in an immunosuppressed patient.
Well done, you are a winner
Thank you for your reply; both the left and bilateral nephrectomy are correct. Those suggested bilateral nephrectomy based on symptoms on the right side, a large cyst with active bleeding on the left side, and 2 small cysts on the right side with active bleeding. On the other hand, left nephrectomy alone is also correct since the symptoms are not severe on the right side, and there is an obvious advantage from unilateral nephrectomy is also correct since conservative treatment for the right side is a valid option. Removing the right kidney alone (unilateral nephrectomy) is the wrong answer.
According to the CT scan view, the masses are huge and are below the iliac rest, so there is a %100 indication of nephrectomy. Unilateral may be theoretically enough, but bilateral would be better mainly because:
the other kidney with multiple cysts will confer with our follow-up, pain, hematuria, cyst infection and even malignancy
in addition, we may face surgical issues
planning which kidney will be transplanted to which side depends on the length of the vessels of the donated kidney and the anatomy of the recipient.
************
In addition, back to the original scenario, we can not expect which kidney will cause problem more. The left side may bother us. we can not use many analgesics in patients on multiple nephrotoxic drugs, and we can not afford sepsis risk in an immunosuppressed patient.
*******
Something to remember, simultaneous bilateral nephrectomy is expected to cause profound hypotension and increase the need for volume repletion and high doses of vasoconstrictor in parallel to the loss of the RAS system and the absence of angiotensin vasoconstriction effect.
Note: system did not allow the last note to be added (so I put the answer in a new reply)
Dear Professor Halawa
I would plan for a unilateral nephrectomy to create space for the graft. We can do a staged procedure if bilateral nephrectomies were needed. But in this case as he does not have another indication apart for space for the graft kidney. i would go for a unilateral kidney.
I would like to share my experience about a patient referred to us for a kidney transplant. He had ADPKD and bilateral nephrectomies done due to recurrent infections before being referred. So, he was on thrice weekly hemodialysis. The challenge was his blood pressure. They were persistently low < 90/60 mmHg. It became quite challenging even for dialysis. The worry also was during the transplant procedure and post-transplant – how to maintain the BPs to achieve MAPs of > 65 mmHg. We could have used vasopressors but they would affect the graft negatively due to the vasoconstriction.
I was kindly requesting for everyone’s input in this case
Thank you
Well done, you are a winner
Thank you for your reply; both the left and bilateral nephrectomy are correct. Those suggested bilateral nephrectomy based on symptoms on the right side, a large cyst with active bleeding on the left side, and 2 small cysts on the right side with active bleeding. On the other hand, left nephrectomy alone is also correct since the symptoms are not severe on the right side, and there is an obvious advantage from unilateral nephrectomy is also correct since conservative treatment for the right side is a valid option. Removing the right kidney alone (unilateral nephrectomy) is the wrong answer.
the current case mostly will require bilateral nephrectomy. However, starting with left native nephrectomy, which has large hemorrhagic cyst (hyperdense rounded lesion in the left kidney) , to avoid the risk of kidney rupture and massive blood loss during transplant operation and also to allow room for the graft as both native kidneys are huge (below iliac crests). This can be done 1.5_3 months prior to transplantation.
_ the right kidney should be removed post transplant as it may be a focus of infection post transplant (especially with start of immunosupressive therapy) , also due to the presence of ares of hemoarrage ( hyperdense) and areas of degeneration. On addition, the patient has rt loin pain and the liver appears compressed.
_ the staged approach of bilateral nephrectomy has 2 benefits: preservation of the residual kidney function till the time of transplantation and also avoidance of severe hypotension ( due to loss of RAAS system).
In addition , it was proven that post transplant nephrectomy does not worsen the graft outcome unlike simeltaneous nephrectomy with transplant operation which can affect graft function and cause (DGF).
_Reference
_ Chebib FT, Prieto M, Yeonsoon J, Irazabal MV, Kremers WK, Dean PG, Rea DJ, Cosio FG, Torres VE, El-Zoghby ZM. Native nephrectomy in renal transplant recipients with autosomal-dominant polycystic kidney disease. Transplantation direct. 2015 Nov;1(10).
Well done, you are a winner
Thank you for your reply; both the left and bilateral nephrectomy are correct. Those suggested bilateral nephrectomy based on symptoms on the right side, a large cyst with active bleeding on the left side, and 2 small cysts on the right side with active bleeding. On the other hand, left nephrectomy alone is also correct since the symptoms are not severe on the right side, and there is an obvious advantage from unilateral nephrectomy is also correct since conservative treatment for the right side is a valid option. Removing the right kidney alone (unilateral nephrectomy) is the wrong answer.
Its a multidisciplinary approach involving both the transplant surgeon and the interventionist radiologist for proper decision and plan of care.
As far as the arterial phase CT is showing an enhancement bilaterally, more prominent in the left kidney , consistent with aneurysmal dilatation of renal arteries bilaterally with massive enlargement in the left kidney.
Plan:
Bilateral nephrectomy is recommended due to the higher risk of bleeding and rupture of the aneurysm .
Well done, you are a winner
Thank you for your reply; both the left and bilateral nephrectomy are correct. Those suggested bilateral nephrectomy based on symptoms on the right side, a large cyst with active bleeding on the left side, and 2 small cysts on the right side with active bleeding. On the other hand, left nephrectomy alone is also correct since the symptoms are not severe on the right side, and there is an obvious advantage from unilateral nephrectomy is also correct since conservative treatment for the right side is a valid option. Removing the right kidney alone (unilateral nephrectomy) is the wrong answer.
The CT image shows a large hemorrhagic cyst in left kidney. The patient had history of RIGHT flank pain which subsided with symptomatic treatment. Also, an episode of UTI was managed well with antibiotics.
The Kidneys are going below the iliac crest.
Hence the indication for nephrectomy in this case is to create space for the graft kidney and not due to some symptoms/ infection.
In this scenario, unilateral nephrectomy would suffice due to increased risks of bleeding and increased operative time for bilateral nephrectomy.
Considering the large hemorrhagic cyst in the left kidney, I would prefer a unilateral left nephrectomy in this patient.
Well done, you are a winner
Thank you for your reply; both the left and bilateral nephrectomy are correct. Those suggested bilateral nephrectomy based on symptoms on the right side, a large cyst with active bleeding on the left side, and 2 small cysts on the right side with active bleeding. On the other hand, left nephrectomy alone is also correct since the symptoms are not severe on the right side, and there is an obvious advantage from unilateral nephrectomy is also correct since conservative treatment for the right side is a valid option. Removing the right kidney alone (unilateral nephrectomy) is the wrong answer.
Let’s agree this patient he should go for NN prior to transplant for space
then we have to decide about unilateral. Or bilateral and the timing this need MDT approach takening in consideration. The type of donor LD Tx vs DD TX. And our urologist preference with local experience as I can see if we are going for unilateral nephrectomy. Which is preferred over bilateral with less complications in term of surgical complications. Infection and volume load Mamagment with hypotension risk with anuric bilateral nephrectomy
in this particular case if LD Tx will go for lt sided NN for space and complicated hemorrhage of one cyst 6-3 months prior to LD Tx. If DDTx still will can go for unilateral lt sided nephrectomy at same time of TX for space and avoid the complicated bleeding cyst in lt side
Well done, you are a winner
Thank you for your reply; both the left and bilateral nephrectomy are correct. Those suggested bilateral nephrectomy based on symptoms on the right side, a large cyst with active bleeding on the left side, and 2 small cysts on the right side with active bleeding. On the other hand, left nephrectomy alone is also correct since the symptoms are not severe on the right side, and there is an obvious advantage from unilateral nephrectomy is also correct since conservative treatment for the right side is a valid option. Removing the right kidney alone (unilateral nephrectomy) is the wrong answer.
This patient had huge bilateral pck,as we see in the CT the left kidney had huge cyst but the patient complained of right flank pain and there’s two stones in the right kidney with episode of UTI ;That why I will go for bilateral nephrectomy
Well done, you are a winner
Thank you for your reply; both the left and bilateral nephrectomy are correct. Those suggested bilateral nephrectomy based on symptoms on the right side, a large cyst with active bleeding on the left side, and 2 small cysts on the right side with active bleeding. On the other hand, left nephrectomy alone is also correct since the symptoms are not severe on the right side, and there is an obvious advantage from unilateral nephrectomy is also correct since conservative treatment for the right side is a valid option. Removing the right kidney alone (unilateral nephrectomy) is the wrong answer.
The CT scan showed bilateral enlarged kidneys crossing the iliac crests. Also there are bilateral hemorrhagic cysts and left kidney contains the largest one .This pt needs creation of space to perform kidney transplantation .As his left kidney carries the highest risk for bleeding,it is better to perform left native nephrectomy (treatment for the existing pathology plus creation a space for the graft ) . Nehrectomy can be perform at time of transplantation . Bilateral nephrectomy increases the risk of hypotension, that may jeopardize graft function .
Well done, you are a winner
Thank you for your reply; both the left and bilateral nephrectomy are correct. Those suggested bilateral nephrectomy based on symptoms on the right side, a large cyst with active bleeding on the left side, and 2 small cysts on the right side with active bleeding. On the other hand, left nephrectomy alone is also correct since the symptoms are not severe on the right side, and there is an obvious advantage from unilateral nephrectomy is also correct since conservative treatment for the right side is a valid option. Removing the right kidney alone (unilateral nephrectomy) is the wrong answer.
The patient has an attack of pain on the right side pain and UTI. I think the first step is to evaluate the patient clinically. if he is hemodynamically unstable, there is a possibility of a ruptured cyst or pyelonephritis(the infected cyst is difficult to be treated) and this will require stabilization of the general condition and bilateral nephrectomy before transplantation.
If the patient is hemodynamically stable, I will recommend removing the left kidney first(large haemorrhagic cyst with a high incidence of complication and after 6 weeks, I will proceed to remove the right kidney before transplantation. the site of transplantation will be decided according to the Donor’s kidney(right or left).
Well done, you are a winner
Thank you for your reply; both the left and bilateral nephrectomy are correct. Those suggested bilateral nephrectomy based on symptoms on the right side, a large cyst with active bleeding on the left side, and 2 small cysts on the right side with active bleeding. On the other hand, left nephrectomy alone is also correct since the symptoms are not severe on the right side, and there is an obvious advantage from unilateral nephrectomy is also correct since conservative treatment for the right side is a valid option. Removing the right kidney alone (unilateral nephrectomy) is the wrong answer.
This patient had bilateral huge kidneys with bilateral multiple haemorrhagic cysts with obvious big one in the left kidney (tumours and ruptured aneurysms needs to be excluded)
Bilateral nephrectomy is indicated in this case
Native bilateral nephrectomy is indicated for patients with large kidneys causing pressure symptoms, infection, bleeding, HTN, to create space for a renal allgraft and suspicious of malignancy
If recipient have no living donor (on the waiting list), nephrectomy should be reserved for patients with severe mechanical or infectious complains, as the majority of patients will die before receiving a transplantation
I will do sequential nephrectomy (bilateral nephrectomy is a major operation with high post-operative complications), and to avoid hypotension, dialysis (if not on), and anaemia
In this case removal of the left kidney first (laparoscopic if possible) as the big cyst is more liable to rupture, and possible suspicion of malignancy. Nephrectomy of the right kidney simultaneously with transplant operation
Well done, you are a winner
Thank you for your reply; both the left and bilateral nephrectomy are correct. Those suggested bilateral nephrectomy based on symptoms on the right side, a large cyst with active bleeding on the left side, and 2 small cysts on the right side with active bleeding. On the other hand, left nephrectomy alone is also correct since the symptoms are not severe on the right side, and there is an obvious advantage from unilateral nephrectomy is also correct since conservative treatment for the right side is a valid option. Removing the right kidney alone (unilateral nephrectomy) is the wrong answer.
unilateral nephrectomy as there is bleeding in the cyst
CT contrast abdomen is done for this patient which showed large left hemorrhagic cyst…right kidney shows 2 small cysts…It also shows the kidneys extending below the pelvic crest….
The patient had history of right flank pain which settled with mild analgesia….there is also 1 episode of UTI only which settled with antibiotic….There is definite indication for bilateral nephrectomy in this case due to large kidneys extending to the pelvis…Impending rupture of the left kidney due to big cyst…Right side also there are numerous cysts which can bleed in the future..
So the options are left nephrectomy as the first choice….preserving the other kidney will do the best in terms of preserving residual renal functions and maintenance of a pool for circulating DSA if any….
If surgical expertise is present and after a multi disciplinary approach a bilateral nephrectomy can also be done, but maintaining the patient on dialysis is difficult till transplant
Right sided alone nephrectomy is not advised
this is a CT abdomen arterial phase showing hugely enlarged kidneys cystic the left one showed a large cyst with active bleeding, and the right one showed small cysts with active bleeding.
the patient had symptoms regarding his right kidney , but they still could be controlled by analgesia and UTI controlled by antibiotic
so, the options would be lt nephrectomy or bilateral nephrectomy
better done before transplantation
laparoscopic approach has the advantages of reducing hernia incidence, less blood transfusion, and less sensitization, and less incision size but more time-consuming and may not be appropriate for kidney size more than 1500 ml or in case of sepsis
reference:
Lubennikov AE, Petrovskii N V., Krupinov GE, Shilov EM, Trushkin RN, Kotenko ON, et al. Bilateral Nephrectomy in Patients with Autosomal Dominant Polycystic Kidney Disease and End-Stage Chronic Renal Failure. Nephron. 2021;145(2):164–70.
In this case, the patient still does not meet the criteria for performing nephrectomy, but the presence of cysts may lead us to doubt as to the presence of malignant disease and also the risk of repeated infections. The role of bilateral nephrectomy would be to rule out these two risks and it should be performed bilaterally because we noticed these findings in both kidneys.
a scheduled bilateral nephrectomy prior to kidney transplantation was conducted in 114 patients who either underwent a native nephrectomy prior to , during , or after kidney transplantation. There were no statistically significant differences in postoperative morbidity after nephrectomy nor differences in kidney transplant outcome. Bilateral nephrectomy prior to kidney transplantation is a safe, controlled approach carrying minimal complication and mortality rates and facilitating a subsequent transplant procedure without mechanical or hemodynamic limitations for the graft.(1) Staged unilateral laparoscopic nephrectomy was superior to the bilateral procedure in perioperative outcome. (2) A retrospective case-control design has been organized in three Groups on the basis of nephrectomy: in the Group I, bilateral nephrectomy prior to transplantation, Group II unilateral nephrectomy before RT and Group III represents the control group (pts who maintained their native asymptomatic kidneys along their transplant life).Patient survival was 100%, 99%, 98% (pNS) at one year and 96%, 96%, 98% (p=0.4) at five years in the Group I, II, III, respectively. In the Group I no patients died from sepsis, whilst in the Group II and III, 5 and 4 pts respectively died for sepsis between 2 months and 8 years after transplantation. Moreover, two pts out of the 45 submitted to removal of polycystic kidney at transplant operation to make space for the new graft had to be re-operated due to infection of blood and lymph collection. So, pre-transplant bilateral nephrectomy remains the gold standard for PKD-pts candidate to renal transplant.(3)
1-Alkaissy, R.T.S.; Schaapherder, A.F.M.; Baranski, A.G.; Dubbeld, J.; Braat, A.E.; Lam, H.-D.; Nijboer, W.N.; Nieuwenhuizen, J.; de Vries, D.K.; Huurman, V.A.L.; Alwayn, I.P.J.; van der Bogt, K.E.A. Timing of Nephrectomy and Renal Transplantation in Patients with Autosomal Dominant Polycystic Kidney Disease (ADPKD) in the Era of Living Kidney Donation. Transplantology 2020, 1, 43-54. https://doi.org/10.3390/transplantology1010005
2-Lucas SM, Mofunanya TC, Goggins WC, Sundaram CP. Staged nephrectomy versus bilateral laparoscopic nephrectomy in patients with autosomal dominant polycystic kidney disease. J Urol. 2010 Nov;184(5):2054-9. doi: 10.1016/j.juro.2010.06.150. Epub 2010 Sep 18. PMID: 20850813
3- Berardinelli, L. ; Raiteri, M.; Pasciucco, A.; Giussani, A.1,Indications, Timing and Results of Nephrectomy in 260 Kidney Transplant Patients Affected by Polycystic Kidney Disease,1895,Transplantation 94(10S):p 908, November 27, 2012.
Native kidneys tend to regress in volume after kidney transplantation, which supports the opinion of leaving native kidneys in place
Indications for native kidney nephrectomy :
1 recurrent infection associated with nephrolithiasis.
2 Stones requiring nephrectomy are usually complicated (stag-horn stone) or infected (struvite stone) .
3 malignancy
4 vesicoureteral reflux, the presence of recurrent pyelonephritis − especially when accompanied by a nonfunctioning kidney
5 huge kidney size crossing the iliac crest .
6 sever refractory hypertension (renin dependent HTN).
7 persistent heavy proteinuria.
8 Intractable pain.
9 hemorrhage inside a cyst
In this case, there are huge bilateral kidneys most probably causing increase in the intraabdominal pressure and gastrointestinal manifestations as fullness ,vomiting and malnutrition , both shows hemorrhagic cysts,2 small cysts in the right kidney and one large cyst in the left kidney.
i prefer to do bilateral nephrectomy before transplantation.
reference
Elrggal ME, Abd Elaziz HM, Gawad MA, Sheashaa HA. Native nephrectomy in kidney transplantation, when, why, and how?. J Egypt Soc Nephrol Transplant [serial online] 2018 [cited 2022 Dec 23];18:68-72.
Clear indications for nephrectomy prior to transplantation include:
· Persistent pain and discomfort,
· Continuous hematuria, recurrent cystic hemorrhage
· Repeated severe cyst infections,
· Gastrointestinal symptoms such early satiety,
· Recurrent nephrolithiasis
· Risk of malignancy
In this case :
Bilateral huge polycytic kindeys with presence of hemorrhagic cysts in the both kidneys so I will proceed for bilateral nephrectomy starting with the left kidney as it has a large hemorrhagic cyst
References:
Akoh JA. Current management of autosomal dominant polycystic kidney disease. World J Nephrol. 2015;4:468–479.
A case of adult polycystic kidney disease
The kidneys are hugely enlarged exceed the iliac crest.
There is a large cyst of active bleeding on left side, two small cysts of active bleeding in right side , right side symptoms are controllable.
the plan is to do nephrectomy , either bilateral nephrectomy or left side
left side is the more complicated side, it is correct to do unilateral nephrectomy of the left kidney and as right side is less complicated and symptoms are not severe.
or to do bilateral nephrectomy as symptoms from the right and the left one is complicated.
.
nephrectomy is not routine practice before kidney transplant because it is associated with anemia, loss of residual kidney function exposing patients to dialysis and its complications so, it is limited for special situations like
back to this case: the left kidney shows a large hemorrhagic cyst and the right kidney shows 2 small hemorrhagic cysts and both of them are huge exceeding the iliac crest. our center’s experience regarding this cases we used to do nephrectomy for the most complicated kidney which will be the left one 1 month pretransplant and do a right nephrectomy simultaneous with kidney transplantation at the same time and place.
References:
1.Sanfilippo FP, Vaughn WK, Peters TG, Bollinger RR, Spees EK. Transplantation for polycystic kidney disease. Transplantation 1983; 36:54-9.
2.Calman KC, Bell PR, Briggs JD, et al. Bilateral nephrectomy prior to renal transplantation. Br J Surg 1976; 63:512-6.
3.Fuller TF, Brennan TV, Feng S, et al. End stage polycystic kidney disease: indications and timing of native nephrectomy relative to kidney transplantation. J Urol 2005; 174:2284-8.
4.Wagner MD, Prather JC, Barry JM. Selective, concurrent bilateral nephrectomies at renal transplantation for autosomal dominant polycystic kidney disease. J Urol 2007; 177:2250-4.
What is the role of bilateral nephrectomy in the pre-transplant work up with special reference to the image below? This patient gave a history of right flank pain which responded well to analgesia and one episode one episode of UTI responded well to antibioticshuge kidneys with bleeding inside cysts
this is a complicated case of bilateral polycystic kidney extending below the iliac crest. lt one complicated with haemorrhage in a large cyst. RT has two small cysts with bleeding inside.
lt nephrectomy needs to be done first. then Rt kidney nephrectomy at time of transplantation can be done also.
The CTU shows large hemorrhagic cyst .
His right sided symptoms of colic and UTI is mild ,which suggest Left nephrectomy
,though bilateral can be done ,for this large space occupying kidney.
Native nephrectomy in above patient with ADPKD:
is considered when patients suffer from recurrent urinary tract infections,
Refractory hematuria.
Chronic pain refractory to conservative treatment.
the indication of bilateral nephrectomy are history of recurrent UTI , limitation of daily activity fatigue and anorexia, suspected malignancy,space for renal transplant, and uncontrolled renal haemorrhage among patients who have a contraindication or failure and development of renal hernia due to renomegally.
in this case, I prefer unilateral left nephrectomy because of the left haemorrhage cyst because bilateral nephrectomy it takes longer and postoperative paralytic ileus
reference UpToDate
this patient had sever ADPCKD with right side pain.
Image shows bilateral cyst hemorrhage mainly at left side. this hemorrhage may be part of underlying associated malignancy.
i will plan for bilateral nephrectomy. but as a rule for more conservative therapy unilateral nephrectomy is better then bilateral one , left side nephrectomy first then the right side performed.
Nephrectomy is a must for the affected kidney (lt kidney in this case) also bilateral nephrectomy is better to avoid further complications in the future
Usually the indications for nephrectomy prior to transplant in case of:
1- Multiple kidney stones
2- recurrent UTI
3- intractable huge into cyst in PKD
4- malignancy
Nephrectomy is not the standard procedure prior to transplantation. Unilateral nephrectomy is preferred to bilateral nephrectomy , being a huge operation requiring dissection in both retroperitoneal fossae, more post-operative complications including paralytic ileus, anemia and hypotension due to loss of the RAAS system.
In the above scenario, both kidneys are very large extending below the iliac crest, but the one on the LT is showing a large hemorrhagic cyst more liable to infection and rupture, while the RT kidney has 2 smaller cysts.
I will proceed to LT laparoscopic nephrectomy first (carrying more pathology)to provide appropriate space for the graft and then proceed for the transplantation after 4-12 weeks later. If the other kidney continued to be troublesome, the patient can be completely nephrectomized through a delayed laparoscopic nephrectomy after recovery from transplant procedure.
Reference
Yucel, TS et al. Which One Should We Perform for Native Nephrectomy in Renal Transplant Recipients with Polycystic Kidney Disease: Bilateral or Unilateral Nephrectomy? Eight Years’ Experience in Our Transplantation Centre. JOJ uro & nephron. 2017; 2(3): 555589.
According to supplied data, this patient will need sequential nephrectomy to be started with the left one,there is a large cyst located the left kidney ,may need further evaluation , also in the schedule of transplantation these two kidneys are really huge even crossing the iliac crest line. After one month average the right kidney can be removed on the setting of renal transplantation.
Right renal nephrectomy is not urgent as the UTI episode responded well to treatment and the loin pain is ameliorated by analgesia
Delay transplant schedule.
suggestive for bilateral nephrectomy.
*This patient has massive APKD with a left large hemorrhagic cyst.
*Native nephrectomy of ADPKD is only indicated when: recurrent infection, hematuria , to make a bed space for renal graft and this is done intra-operative at same set of renal transplantation, interactable pain un-responding to analgesics , and CT suspicion of malignancy .So, in the above case scenario i would rather prefer to do unilateral left native nephrectomy due to large hemorrhagic cyst included while pain from right flank is controllable with analgesia and antibiotics.
4. What is the role of bilateral nephrectomy in the pre-transplant work up with special reference to the image below
Unilateral neprectomy to left kidney
The symptoms of the rihlght kidney is not sever and respond well to medication
he requiresunilateral left nephrectomy, as there is evidence of active hemorrhage in cyst on left side.
Left nephrectomy is the most wise decision 9 large bleeding cyst) and preferred to bilateral nephrectomy as long as symptomatic rt kidney managed medically. Then proceeding for renal transplantation after 1-2 months, when rt nephrectomy could be done at the same time if indicated.
I suggest bilateral nephrectomy as there is hemorrhage on both sides
indication of surgical bilateral nephrectomy before transplant include:
1- hypertension resistant to medical treatment
2-persistent symptomatic renal infection
3- severe proteinuria
4-occasionally polycystic kidneys
5- bilateral renal tumors
patient has ADPCK and gave a history of left flank pain which responded well to analgesia and one episode of UTI which responded well to antibiotic.
patient liable for recurrent UTI and recurrent need of antibiotic also has pain attack and there is large cyst in left kidney may cause recurrent pain need analgesic more burden transplanted kidney
large cyst liable to cause hematuria , infection , rupture and transfer to malignant.
also huge both kidneys and no space for transplanted kidney so nephrectomy is best option
Handbook Of Kidney Transplantation
Indications for Pretransplantation Native Nephrectomy
In this senario, I agree with the opinion of unilateral left nephrecomy to remove the hemorrhagic cyst , then would later go for transplantation operation – 2 step operation.
CT scan shows enlarged polycystic kidneys going below the iliac crest. Also some of the cyst are hemorrhagic with a huge hemorrhagic cyst in the left. I would definitely arrange for left nephrectomy. On the other hand a bilateral nephrectomy should be considered in view of right iliac pain associated with small haemorrhagic cyst (on the right) and the kidney size going below the iliac crest (both right and left kidney) leaving not enough space for the graft.
Indication of nephrectomy prior kidney tx
1. Infected stone
2. Infected reflux (uninfected reflux dose not require nephrectomy)
3. APKD (massive, recurrent bleeding & recurrent infection)
4. Acquired cystic kidney disease (risk of malignancy)
5. Heavy proteinuria
6. Intractable hypertension
7. Failed medical nephrectomy for the indications listed above
however, in this scenario, I prefer unilateral nephrectomy to keep residual kidney function,, avoid anemia, less surgical complications
For this patient, symptoms are not severe and responded to treatment, but there is a large cyst on the left side which is an indication of left nephrectomy; in addition, left nephrectomy will give space to the transplanted kidney as both native kidneys are so large.
This patient has huge polycystic kidney disease with a large hemorrgaic cyst at the left upper kidney.
Native nephrectomy of ADPKD is generally performed for recurrent infection, haematuria, space, chronic pain, and tumour suspicion on imaging. Native bilateral nephrectomy is indicated for patients with large kidneys causing pressure symptoms, pain, infection, bleeding, hypertension, and suspicion of malignancy; this operation is also indicated to create space for a renal allograft.
Native nephrectomy indications in APKD include:
-Chronic intractable pain ( needing narcotics , affecting quality of life) not the case here.
-Recurrent cyst infection , rupture , or hemorrhage( evident right and left )
-Huge kidney size hindering the room for the RTx( both kidneys are below the level of the iliac crest .
*GIT symptoms :recurrent vomiting out of fullness(not the case here).
*Recurrent UTI’s(only one episode mentioned here).
So here in this case i would prefer along with urosurgical consultation go for pre transplant left nephrectomy and then at the same setting after a month ( if all good) right native nephrectomy with graft transplantation in the right iliac fossa.
Good morning sir,
I would prefer bilateral simultaneous pretransplant native nephrectomy as
I would prefer bilateral Laparoscopic simultaneous nephrectomy with small midline incision enough to retrieve the kidneys.
We have been following this protocol at our institute.
This would be followed by transplant after 7 to 10 days of healing and recovery.
Well, the first thing in this patient is that there is an infection and hemorrhagic cyst. The kidneys are enlarged, and both are occupying space in the abdomen for possible transplant. Pre-transplant space is needed and as such both kidneys must be removed. The question is should both be removed at the same time one before the other during a certain period of time?
From different articles, they share different views. Some suggest bilateral nephrectomy while others suggest one at a time with some period differences which can be months or even years.
Bilateral nephrectomy is a massive surgery and as such, it should be delt with caution as the complication is greater in it like massive bleeding, infection, shock, and even death.
I would in my opinion do one kidney at a time to reduce the above complications and as such guarantee a better outcome for the patient. While the last kidney is being removed and the donor’s kidney is available then the transplant can be done during the first nephrectomy if the patient is ready.
First we remove the left kid due to presence of hemorrhage in the cyst and if still the indication remains like recurrent bleeding into cysts or severe haematuria or recurrent sepsis we can do another operation to remove the second kid with 6 weeks interval between the 2 operations and we can do the second nephrectomy at the time of transplantation.
Bilateral nephrectomies are rarely performed and are mostly indicated for patients who have a severe limitation of daily activities due to massive renomegaly, severe kidney pain refractory to pharmacologic management, recurrent bilateral infections, or malnutrition.
Bilateral nephrectomy is not necessary when making space for transplant is the indication. It takes much longer and post-operative paralytic ileus for having dissection of both retroperitoneal fossa can be a troublesome post-operative complication that does happen in one-sided nephrectomy for polycystic kidney (PCK)
Reference
up to date
What is the role of bilateral nephrectomy in the pre-transplant work up with special reference to the image below?
▪︎This patient gave a history of right flank pain which responded well to treatment and one episode one episode of UTI responded well to antibiotic.The CT scan shows huge kidneys extended below the iliac crest.
▪︎In this scenario there is strong indications for nephrectomy ( to create space for transplantation) also there is history of pain and infection.
▪︎ Unilateral nephrectomy (the left kidney due to the large hemorrhagic cyst) can be done before transplantation.
Bilateral nephrectomy is not routine practice in kidney transplantation
Because
1. bilateral nephrectomy is an operation that has complications like bleeding and blood transfusion and severe hypotension.
2. post-operative patients will become anuric and more liable for volume overload
3. patient on conservative management will need to start dialysis
That’s why bilateral nephrectomy is only needed if the patient
·resistant hypertension not related to volume status and not responding to 3 or more antihypertensive medications and the only explanation is this hypertension is related to native kidneys
·recurrent urinary tract infection with the colonization of native kidney especially if there is septic focus like infected stones
·suspected malignancy
·large native kidneys and there is no available space for graft
·ADPKD with recurrent rupture or risky cyst as regarding impending rupture, infection, or malignancy
·persistant proteinuria not responding to conservative management and medical nephrectomy
Regarding the mentioned case
there is a large risky cyst with hemorrhage inside the left kidney and there is 2 small cyst with hemorrhage inside the right kidney
I would prefer to do a left nephrectomy then after 6-8 weeks do simultaneous right nephrectomy and right kidney transplantation in the same operation
Bilateral nephrectomy is my opinion as both kidneys are hugely enlarged and also has active hemorrhage.
This patient has huge polycystic kidney disease with a large hemorrgaic cyst at the left upper kidney.
Native nephrectomy of ADPKD is generally performed for recurrent infection, haematuria, space, chronic pain, and tumour suspicion on imaging. Native bilateral nephrectomy is indicated for patients with large kidneys causing pressure symptoms, pain, infection, bleeding, hypertension, and suspicion of malignancy; this operation is also indicated to create space for a renal allograft.
In Bellini et al, cohort, the main indication to native bilateral nephrectomy in ADPCKD patients was space in 59% of the cases in the view of a prospective transplant, or because of compression/abdominal fullness, and Recurrent cyst infection in (36%).
For this patient with massive polycystic kidneys, nephrectomy is indicated for creating space to facilitate transplantation. Moreover, he has chronic right flank pain which could be caused by enlarged cysts, cyst rupture and cyst infection. Also, the increased incidence of uric acid nephrolithiasis as a factor in producing renal colic must be considered when evaluating acute pain in such a population. Additionally, malignancy transformation of cysts in APKD patients can occur post-transplantation with immunosuppression. Therefore, I will go for a bilateral nephrectomy for this patient as a pre-transplant.
On the other hand, nephrectomy for enlarged polycystic kidneys in patients with ADPKD is associated with significant complication rates. The most common was the necessity for transfusion, as confirmed by the haemoglobin drop postoperatively in both the transplant and dialysis groups. Literature confirms that avoiding simultaneous nephrectomy and transplantation reduces by approximately 40% the risk for postoperative complications and by 100% the risk for blood transfusion. A death incidence of up to 8.6% following nephrectomies of APKKD has been reported in the literature.
References:
1. Maria Irene Bellini, Sotiris Charalmpidis, Paul Brookes, Peter Hill, Frank J. M. F. Dor, Vassilios Papalois, “Bilateral Nephrectomy for Adult Polycystic Kidney Disease Does Not Affect the Graft Function of Transplant Patients and Does Not Result in Sensitisation”, BioMed Research International, vol. 2019, Article ID 7423158, 6 pages, 2019. https://doi.org/10.1155/2019/74231582. Bajwa ZH, Gupta S, Warfield CA, Steinman TI. Pain management in polycystic kidney disease. Kidney Int. 2001 Nov;60(5):1631-44. doi: 10.1046/j.1523-1755.2001.00985.x. PMID: 11703580.
3. Rafique M. Nephrectomy: indications, complications and mortality in 154 consecutive patients. J Pak Med Assoc. 2007 Jun;57(6):308-11. PMID: 17629234.
Well done, you are a winner
Thank you for your reply; both the left and bilateral nephrectomy are correct. Those suggested bilateral nephrectomy based on symptoms on the right side, a large cyst with active bleeding on the left side, and 2 small cysts on the right side with active bleeding. On the other hand, left nephrectomy alone is also correct since the symptoms are not severe on the right side, and there is an obvious advantage from unilateral nephrectomy is also correct since conservative treatment for the right side is a valid option. Removing the right kidney alone (unilateral nephrectomy) is the wrong answer.
This CT image of PKD, showed huge kidneys extending down into both iliac fossae. Very apparent in the upper pole of the Lt Kid, a huge hemorrhagic cyst with 2 small one in the Rt Kid. This patient will benefit from scheduled bilateral nephrectomy, before transplant procedure for the following reasons:
· Huge kidneys extending into both iliac fossae and space to accommodate the graft is needed.
· There are bilateral hemorrhagic cysts on both side with huge one in the Lt Kid.
· The patient had history of UTI and flank pain responded to treatment and these may recur in the post-transplant period and risk the graft with the use of analgesia or an urgent intervention.
Indications for nephrectomy in PKD:
· recurrent and/or severe infection.
· symptomatic nephrolithiasis.
· recurrent and/or severe bleeding.
· intractable pain.
· suspicion of renal cancer.
· space restrictions prior to transplantation (even considering that kidney size typically declines after transplantation).
Well done, you are a winner
Thank you for your reply; both the left and bilateral nephrectomy are correct. Those suggested bilateral nephrectomy based on symptoms on the right side, a large cyst with active bleeding on the left side, and 2 small cysts on the right side with active bleeding. On the other hand, left nephrectomy alone is also correct since the symptoms are not severe on the right side, and there is an obvious advantage from unilateral nephrectomy is also correct since conservative treatment for the right side is a valid option. Removing the right kidney alone (unilateral nephrectomy) is the wrong answer.
The CT scan showed bilateral enlarged kidneys crossing the iliac crests. Also there are bilateral hemorrhagic cysts and the left kidney contains the largest one .This pt needs creation of space to perform kidney transplantation .As his left kidney carries the highest risk for bleeding,it is better to perform left native nephrectomy (treatment for the existing pathology plus creation a space for the graft ) . Nehrectomy can be perform at time of transplantation . Bilateral nephrectomy increases the risk of hypotension, that may jeopardize graft function .
.
Approaches for pre-transplantation nephrectomy ;
1-A unilateral nephrectomy.
When the least functional kidney is being removed, space has been created for a future kidney transplant while diuresis has been preserved.
2-Bilateral nephrectomy;
Bilateral nephrectomy is accompanied by perioperative decrease in blood pressure that may jeopardize graft function .
3- Robot-assisted procedures;
newly emerging techniques in performing nephrectomies in ADPKD patients , which have been proven to be safe and effective with no major complications and lower estimated blood loss .
Reference ;
1-Patel, P.; Horsfield, C.; Compton, F.; Taylor, J.; Koffman, G.; Olsburgh, J. Native nephrectomy in transplant patients with autosomal dominant polycystic kidney disease. Ann. R. Coll. Surg. Engl. 2011, 93, 391–395.
2- Cornelis, F.; Couzi, L.; Le Bras, Y.; Hubrecht, R.; Dodre, E.; Genevieve, M.; Perot, V.; Wallerand, H.; Ferriere, J.M.; Merville, P.; et al. Embolization of polycystic kidneys as an alternative to nephrectomy before
renal transplantation: A pilot study. Am. J. Transpl. 2010, 10, 2363–2369.
3- Suwabe, T.; Ubara, Y.; Sekine, A.; Ueno, T.; Yamanouchi, M.; Hayami, N.; Hoshino, J.; Kawada, M.; Hiramatsu, R.; Hasegawa, E.; et al. Effect of renal transcatheter arterial embolization on quality of life in patients with autosomal dominant polycystic kidney disease. Nephrol. Dial. Transpl. 2017, 32, 1176–1183.
4- Millar, M.; Tanagho, Y.S.; Haseebuddin, M.; Clayman, R.V.; Bhayani, S.B.; Figenshau, R.S. Surgical cyst decortication in autosomal dominant polycystic kidney disease. J. Endourol. 2013, 27, 528–534.
5- Torres, V.E.; Chapman, A.B.; Devuyst, O.; Gansevoort, R.T.; Grantham, J.J.; Higashihara, E.; Perrone, R.D.; Krasa, H.B.; Ouyang, J.; Czerwiec, F.S. Tolvaptan in patients with autosomal dominant polycystic
kidney disease. N. Engl. J. Med. 2012, 367, 2407–2418.
Well done, you are a winner
Thank you for your reply; both the left and bilateral nephrectomy are correct. Those suggested bilateral nephrectomy based on symptoms on the right side, a large cyst with active bleeding on the left side, and 2 small cysts on the right side with active bleeding. On the other hand, left nephrectomy alone is also correct since the symptoms are not severe on the right side, and there is an obvious advantage from unilateral nephrectomy is also correct since conservative treatment for the right side is a valid option. Removing the right kidney alone (unilateral nephrectomy) is the wrong answer.
This patient has huge PKD with hemorrhagic cysts and UTI who responded well to medical treatment and the only remaining indication of nephrectomy is absence of suitable space for graft because native kidneys are completely below the iliac crests. But , unilateral nephrectomy will be more safe and practical in this situation. So, I recommend unilateral nephrectomy in this case.
Which side, Nasrin?
Your answer is not clear
I would choose to do unilateral nephrectomy first to avoid dialysis and complications of bilateral nephrectomy .
Dear Prof.Ahmad Sir
Thank you for your concern and also sorry for late reply
After reviewing the studies and evidences.
For this patient,he need to go undergo nephrectomy.I think this patient needs interval bilateral nephrectomies.will remove left one first and then second one after transplantation.
Well done, you are a winner
Thank you for your reply; both the left and bilateral nephrectomy are correct. Those suggested bilateral nephrectomy based on symptoms on the right side, a large cyst with active bleeding on the left side, and 2 small cysts on the right side with active bleeding. On the other hand, left nephrectomy alone is also correct since the symptoms are not severe on the right side, and there is an obvious advantage from unilateral nephrectomy is also correct since conservative treatment for the right side is a valid option. Removing the right kidney alone (unilateral nephrectomy) is the wrong answer.
More obvious reason for nephrectomies is mechanical relief for the patient.
For our patient has history of left flank pain which responded well to analgesia and one episode of haematuria which did not require a specific treatment. The kidneys are extended beyond the iliac crest and inadequate space for new kidney.
Whether to do nephrectomy?
Some studies suggest that both native kidneys should be removed before transplantation to lower the risk for cyst infection when the patient is transplanted and consequently uses immunosuppressive agents that may predispose to and complicate cyst infections
Another argument to prefer pretransplantation nephrectomy in all ADPKD patients is the risk of kidney allograft damage due to hypotension or infection related to surgery when nephrectomy is to be performed posttransplantation on indication. However,Chebib et al. reported that nephrectomy does not negatively affect graft survival and is feasible when indicated
Timing of nephrectomy
Combined nephrectomy and transplantation procedure can be performed to reduce the number of surgeries. Abrol et al. analyzed in 148 ADPKD patients whether a combined laparoscopic bilateral nephrectomy and kidney transplantation is safe compared to kidney transplantation alone. Patients who underwent a combined procedure had longer cold ischemia time, more often a need to be admitted to an intensive care unit, more need for blood transfusions, and a longer duration of hospital stay. After discharge, however, kidney function was comparable in both groups and no difference was found in delayed graft function nor in the incidence of other severe complications.
However, this is a single surgeon series, in which the surgeon has extensive experience in such a complicated, combined procedure, which is likely to have beneficially influenced the results that were obtained. Most of the centers in our country done by various surgeon and this result could not extrapolated to our centers.
Studies also shown that restrictive approach nephrectomy pre or post transplantation did not differ in kidney allograft outcome and complications post transplantation.
Unilateral or bilateral Nephrectomy
There are studies shown bilateral nephrectomy has been comparable with unilateral nephrectomy. However, Bilateral nephrectomy causes patients to be anephric and anuric. As a result, patient will be dialysis dependent and will have to have a fluid restriction when there is no living donor yet. Patient who initiated on dialysis has higher mortality and significant lower of quality of life. Bilateral nephrectomy is associated with perioperative hypotension and may require extra monitoring in the post anesthesia care unit and requirement of inotropes.
After reviewing the studies and evidences,
For this patient, he need to undergo nephrectomy due to
1- no space for kidney allograft- the native ADPKD extended beyond iliac crest bilaterally.
2- Left flank pain with CT evidence of haemorrhagic cyst.
Second is unilateral or bilateral native nephrectomy?
I would choose to do unilateral nephrectomy to avoid dialysis and complications of bilateral nephrectomy
Third, When to do nephrectomy?
I would prefer to do pre transplant nephrectomy 4-6 weeks before transplant. for most centres staged nephrectomy is best to avoid unexpected complications and increase the cold ischaemic time on transplant day.
My choice will be Left native nephrectomy pre – transplantation for this patient.
Well done, you are a winner
Thank you for your reply; both the left and bilateral nephrectomy are correct. Those suggested bilateral nephrectomy based on symptoms on the right side, a large cyst with active bleeding on the left side, and 2 small cysts on the right side with active bleeding. On the other hand, left nephrectomy alone is also correct since the symptoms are not severe on the right side, and there is an obvious advantage from unilateral nephrectomy is also correct since conservative treatment for the right side is a valid option. Removing the right kidney alone (unilateral nephrectomy) is the wrong answer.
More obvious reason for nephrectomies is mechanical relief for the patient.For our patient has history of left flank pain which responded well to analgesia and one episode of haematuria which did not require a specific treatment. The kidneys are beyond the iliac crest and inadequate space for new kidney. The patient had left flank pain and the CT scan showed haemorrhagic cyst. I would do native left nephrectomy pre transplantation.
Although some studies have shown that bilateral nephrectomies is comparable with unilateral nephrectomies but, Bilateral nephrectomy known to have causes patients to ne anephric and anuric. As a result, patient will be dialysis dependent and will have to have a fluid restriction when there is no living donor yet. Patient who initiated on dialysis has higher mortality and significant lower of quality of life. Bilateral nephrectomy is associated with perioperative hypotension due to and may require extra monitoring in the post anesthesia care unit and requirement of inotropes.
Timing of nephrectomy was analysed by multiple studies. The results is proving that staged nephrectomy followed by kidney transplantation is associated with a longer cumulative operative time and increased cumulative risk of blood transfusions. There is no evidence to suggest that performing a simultaneous nephrectomy and kidney transplant procedure increases the perioperative mortality rate, major postoperative complication rates or risk of vascular thrombosis. The Timing of the nephrectomy depends on the surgeon and centre experiences. But most centres prefer to do it early pretransplanatation
Well done, you are a winner
Thank you for your reply; both the left and bilateral nephrectomy are correct. Those suggested bilateral nephrectomy based on symptoms on the right side, a large cyst with active bleeding on the left side, and 2 small cysts on the right side with active bleeding. On the other hand, left nephrectomy alone is also correct since the symptoms are not severe on the right side, and there is an obvious advantage from unilateral nephrectomy is also correct since conservative treatment for the right side is a valid option. Removing the right kidney alone (unilateral nephrectomy) is the wrong answer.
Will you do unilateral nephrectomy or bilateral nephrectomy in this case ?
bilateral nephrectomy is indicated in this case
why?
1-huge kidney extending below the iliac crest , to allow space for the transplanted kidney
2-suspicion of malignancy ( haematuria , weight loss , radiological suspicion of complex cyst)
3-recurrent infection
4-intractable pain not relived by analgesia
5-abdominal symptoms resulting from compression on the adjacent structures , haemorrhage & cyst rupture
regarding the case here , there is huge bilateral kidneys extending the iliac crest & compressing the liver , bilateral haemorrhagic cysts , cysts are suspicious to be complicated with RCC cannot be ruled out depending on the criteria of the cysts & presence of haematuria .
so , here bilateral nephrectomy is indicated
timing & procedure ?
1- staged bilateral nephrectomy , here i will prefer to go Left nephrectomy 6 wks -3 months pre transplant , allowing to remain independent of dialysis, reduce the risk of cyst-related complications, and creating space for the transplanted kidney.
2-After this, a transplant procedure would be performed with no additional intraoperative procedures.
Thus , avoiding unnecessary complications and hazards associated with performing a simultaneous nephrectomy of a large cystic kidney, with the benefit of a less challenging transplant procedure because of the space created by the previous unilateral nephrectomy. Finally , delayed laparoscopic unilateral nephrectomy once recovered from the transplant, benefiting from the minimally invasive nature of this procedure and the well established safety record ( Fungai Dengu et al/Experimental and Clinical Transplantation , 2015)
Well done, you are a winner
Thank you for your reply; both the left and bilateral nephrectomy are correct. Those suggested bilateral nephrectomy based on symptoms on the right side, a large cyst with active bleeding on the left side, and 2 small cysts on the right side with active bleeding. On the other hand, left nephrectomy alone is also correct since the symptoms are not severe on the right side, and there is an obvious advantage from unilateral nephrectomy is also correct since conservative treatment for the right side is a valid option. Removing the right kidney alone (unilateral nephrectomy) is the wrong answer.
Thanks for the interesting scenario.
Well the issues to be considered while planning for unilateral vs bilateral nephrectomy are as follows:
All the above factors can pose a threat for graft dysfunction and is applicable to both native kidneys. Hence I will consider bilateral nephrectomy
Well done, you are a winner
Thank you for your reply; both the left and bilateral nephrectomy are correct. Those suggested bilateral nephrectomy based on symptoms on the right side, a large cyst with active bleeding on the left side, and 2 small cysts on the right side with active bleeding. On the other hand, left nephrectomy alone is also correct since the symptoms are not severe on the right side, and there is an obvious advantage from unilateral nephrectomy is also correct since conservative treatment for the right side is a valid option. Removing the right kidney alone (unilateral nephrectomy) is the wrong answer.
Thanks for the interesting scenario.
Well the issues to be considered while planning for unilateral vs bilateral nephrectomy are as follows:
All the above factors can pose a threat for graft dysfunction and is applicable to both native kidneys. Hence I will consider bilateral nephrectomy
Indications of bilateral nephrectomy before renal transplant are
· Hypertension resistant to medical therapy
· Persistent symptomatic renal infection
· Severe renal protein loss
· Bilateral renal tumors
· Polycystic kidneys ( occasionally )
in the above CT scan there is hugely enlarged kidneys having multiple cysts with cyst hemorrhage bilaterally with least space for graft and history of right flank pain and UTI. So, bilateral nephrectomy prior transplant can be considered.
Well done, you are a winner
Thank you for your reply; both the left and bilateral nephrectomy are correct. Those suggested bilateral nephrectomy based on symptoms on the right side, a large cyst with active bleeding on the left side, and 2 small cysts on the right side with active bleeding. On the other hand, left nephrectomy alone is also correct since the symptoms are not severe on the right side, and there is an obvious advantage from unilateral nephrectomy is also correct since conservative treatment for the right side is a valid option. Removing the right kidney alone (unilateral nephrectomy) is the wrong answer.
This patient needs bilateral nephrectomy as he had Bilateral huge kidney with bilateral hemorrahgic cysts which will cause post operation complication such as hernia ( due to increase intra abdominal pressure ) , risk of bleeding , malnutrition and limitation of daily activity .
left side needs to be removed due to large hemorragic cyst , and right side is very huge and we usually do left donor nephrectomy and transplant the kidney in the RIF
thanks
Well done, you are a winner
Thank you for your reply; both the left and bilateral nephrectomy are correct. Those suggested bilateral nephrectomy based on symptoms on the right side, a large cyst with active bleeding on the left side, and 2 small cysts on the right side with active bleeding. On the other hand, left nephrectomy alone is also correct since the symptoms are not severe on the right side, and there is an obvious advantage from unilateral nephrectomy is also correct since conservative treatment for the right side is a valid option. Removing the right kidney alone (unilateral nephrectomy) is the wrong answer.
INDICATIONS FOR NEPHRECTOMY
Cyst and total kidney size increase progressively over time, even though cyst formation occurs in less than 5 to 10 percent of nephrons [1].
Men over 50 years of age may have enormous kidneys that can reach 40 cm in length (three to four times normal length) and 8 kg in weight, usually associated with significant kidney dysfunction [2]. All other treatable causes of discomfort or reduced quality of life should be ruled out before nephrectomy takes place for this indication.
Unilateral or bilateral nephrectomy may also be considered prior to kidney transplantation in the presence of:
●Recurrent infection.
●Marked limitation of daily activities, fatigue, and anorexia, particularly in the presence of signs of malnutrition.
●Suspected malignancy.
●Extension of the native polycystic kidney into the potential pelvic surgical site. However, there is no indication for routine pretransplant nephrectomies among ADPKD patients.
●Uncontrollable renal hemorrhage among patients who have a contraindication to or failure of intra-arterial embolization.
●Development of ventral hernia due to massive renomegaly.
Nephrectomy can be performed by an open procedure or, if possible, laparoscopically, which shortens the recovery time [2]. Laparoscopic nephrectomy in patients with ADPKD and ESRD offers an effective alternative to open nephrectomy to manage renal-related pain. This procedure provides the benefits of minimal intraoperative blood loss, minimal postoperative pain, brief hospital stay, and rapid convalescence.
Bilateral nephrectomies are rarely performed and are mostly indicated for patients who have a
· severe limitation of daily activities due to massive renomegaly,
· severe kidney pain refractory to pharmacologic management,
· recurrent bilateral infections,
· or malnutrition
Bilateral nephrectomy has more risk of bleeding and anaemia, loss or residual function, more hypotension due to ACE system loss
Timing of nephrectomy: If nephrectomy is required, it should be done 6 weeks to 3 months before transplantation, ideally by laparoscopic technique.
Occasionally, unilateral transplant nephrectomy is performed at the time of the transplant surgery, but this should be avoided if at all possible.[3]
Conclusion: this patient had just one attack of pain and infection easily controlled and just needs follow up, but has huge kidney with no space for transplanted kidney, so he needs unilateral nephrectomy at the moment and may need nephrectomy for the remained polycystic kidney later on if he developed clear indication
[1] https://www.uptodate.com/contents/autosomal-dominant-polycystic-kidney-disease-adpkd-kidney-manifestations?sectionName=INDICATIONS%20FOR%20NEPHRECTOMY&search=polycystic%20kidney%20disease&topicRef=1677&anchor=H8&source=see_link#H8:~:text=kidney%20disease%22.)-,INDICATIONS%20FOR%20NEPHRECTOMY,kidney%20pain%20refractory%20to%20pharmacologic%20management%2C%20recurrent%20bilateral%20infections%2C%20or%20malnutrition,-.
[2] https://www.uptodate.com/contents/autosomal-dominant-polycystic-kidney-disease-adpkd-kidney-manifestations/abstract/33#:~:text=PubMed,2000%3B35(4)%3A720
[3] Handbook of Renal Transplantation. Gabriel M. Danovitch, MD
Which side to start with?
A study by Brazda , et al. revealed higher graft and patient survival rates among ADPKD patients who had undergone a pretransplant unilateral nephrectomy.
Fuller, et al. and Glassman, et al. reported that unilateral native nephrectomy of ADPKD patients concurrent with transplantation is safe if performed from Gibson incision.
Opposing many other studies which demonstrated that pretransplant unilateral or bilateral native nephrectomy is associated with higher mortality and morbidity.
Unilateral nephrectomy with concurrent transplantations is only suggested if the native kidney is too big to occupy the graft kidneys place.
If the patient suffers grade 3-4 vesicoureteral reflux, laparoscopic bilateral native nephrectomy after transplantation period if the native kidneys is the source of recurrent urinary tract infections on the other hand iatrogenic hepatic, splenic, intestinal and gastric injuries, ileus and hemorrhage were reported during bilateral native nephrectomy operations of ADPKD patients.
Compared with bilateral native nephrectomy unilateral nephrectomy provides better patient outcomes such as decreased demand and length of stay in ICU, decreased extra organ injuries and morbidity because of the presence of kidney and suprarenal gland on the other side.
For this case bilateral nephrectomy can be an option since he has large hemorrhagic cyst in the left kidney and his flank pain was on the right side showing small hemorrhagic cyst with high liability of complication also it seems that the native kidney is the source of UTI and if vesicoureteral reflux grade 3-4 is detected bilateral nephrectomy will be better .
Reference
Yucel, Tekin S,Yuksel D, Yucetin L, Yavuz H A, Demirbas A. Which One Should We Perform for Native Nephrectomy in Renal Transplant Recipients with Polycystic Kidney Disease: Bilateral or Unilateral Nephrectomy? Eight Years Experience in Our Transplantation Centre. JOJ uro & nephron. 2017; 2(3): 555589.
Well done, you are a winner
Thank you for your reply; both the left and bilateral nephrectomy are correct. Those suggested bilateral nephrectomy based on symptoms on the right side, a large cyst with active bleeding on the left side, and 2 small cysts on the right side with active bleeding. On the other hand, left nephrectomy alone is also correct since the symptoms are not severe on the right side, and there is an obvious advantage from unilateral nephrectomy is also correct since conservative treatment for the right side is a valid option. Removing the right kidney alone (unilateral nephrectomy) is the wrong answer.
Surgical indications:
1. Create space for future renal transplants.
2. To alleviate pain.
3. preventing recurrent urosepsis.
4. To prevent recurrent bleeding which would require transfusions.
5. Remove a renal tumor.
There is no consensus regarding appropriate treatment for symptomatic patients with ADPKD. Bilateral nephrectomy adequately treats symptoms, but initial studies report high complication rates, with 38% morbidity and 3% mortality. Concerns regarding graft damage and sequelae of a nephric state decrease the nephrectomy rate for ADPKD.
Decision
In this case, the patient has massively enlarged polycystic kidneys he needs bilateral nephrectomy at different times one before transplanting the LT kidney and the other after kidney transplantation the TR kidney to avoid potential negative consequences of concomitant NNx on the outcome of the kidney graft.
The LT kidney first so as to avoid the risk of cystic rupture which may lead to infection, sepsis, need for urgent laboratory or even the need for blood transfusion (since blood transfusion can cause sensitization)
The RT due to the presence of areas of hemorrhage which may increase gradually and lastly became huge also because it became symptomatic and it can be a source of infection
Laparoscopic is advisable because of minimal access surgery, such as reduced estimated blood loss, smaller incision, excellent cosmesis, and faster recovery,
REF:
1. Laparoscopic nephrectomy for massive polycystic kidney disease: Updated technique and outcomes
2.Chebib FT, Prieto M, Yeonsoon J, Irazabal MV, Kremers WK, Dean PG, Rea DJ, Cosio FG, Torres VE, El-Zoghby ZM. Native nephrectomy in renal transplant recipients with autosomal-dominant polycystic kidney disease. Transplantation direct. 2015 Nov;1(10).
Well done, you are a winner
Thank you for your reply; both the left and bilateral nephrectomy are correct. Those suggested bilateral nephrectomy based on symptoms on the right side, a large cyst with active bleeding on the left side, and 2 small cysts on the right side with active bleeding. On the other hand, left nephrectomy alone is also correct since the symptoms are not severe on the right side, and there is an obvious advantage from unilateral nephrectomy is also correct since conservative treatment for the right side is a valid option. Removing the right kidney alone (unilateral nephrectomy) is the wrong answer.