Case Report

Three Approaches for Laparoscopic Unroofing of Simple and Complicated

Renal Cysts
Hiromitsu Mimata,* Hiroaki Mizoguchi, Hitoshi Ohno, Yoshihisa Tasaki,
Toshikatsu Hanada, and Yoshio Nomura
Department of Urology, Oita Medical University, Oita, Japan

We report 2 cases of simple renal cysts which were marsupialized with 2 laparoscopic approaches
involving either transperitoneal, with reflection of the colon medially or dissection through the
mesocolon, and a case of a multilocular renal cyst which was treated by the retroperitoneal approach.
Although laparoscopic unroofing of a renal cyst is a safe and effective alternative to open surgical
techniques, the transperitoneal approach should only be used for simple renal cysts. The retroperitoneal
app,roach for complicated renal cysts may be indicated if preoperative examinations exclude the
possibility of malignancy.
Int J Urol 1997;4:212-218

Key words: renal cyst, laparoscopic surgery, unroofing

found during gastrointestinal evaluation at another

INTRODUCTION
Laparoscopy has made a significant impact on the
practice of urology, as it is minimally-invasive therapy.
Although renal cysts are usually easily managed with
needle puncture and sclerotherapy, several significant
complications have been reported, such as calyx-cyst
or arteriovenous fistulae or ureteropelvic strictures. 1,2
Laparoscopic unroofing or ablation of a simple renal
cyst has been performed and reported to be a safe
alternative to open s ~ r g e r y . ~ - ~
However, the ideal management of complicated
renal cysts remains unclear. Management options
include open exploration, partial or radical
nephrectomy, aspiration, percutaneous resection and
radiologic surveillance. We attempted to marsupialize
a complicated renal cyst with retroperitoneoscopy and
obtained a satisfactory result.
We report 3 approaches for laparoscopic unroofing
of renal cysts. This is the first report on laparoscopic
marsupialization of a complicated renal cyst using a
retroperitoneal approach.
CASE REPORTS
Case 1
A 66-year-old man complained of dull pain in the
right flank for 6 months and a right renal cyst was
Received Jun. 1 1, 1996; accepted for publication in revised form
Oct. 23, 1996. *Correspondence and requests for reprints to: De-
partment of Urology, Oita Medical University, ldaigaoka 1-1,
Hasama-cho, Oita 879-55, japan.
clinic. He was then referred to our hospital, and an
excretory urogram demonstrated nondilated upper
tracts with prompt bilateral excretion. Renal ultra-
sonography and a C T scan (Fig. 1A) of the abdomen
confirmed the location of a large cyst along the ante-
rior aspect and near the hilum of the right kidney.
Under general anesthesia, the patient was placed in
a left decubitus position. A Hasson cannula was posi-
tioned in the inferior crease of the umbilicus. Two
11mm ports were placed 2 cm below the costal mar-
gin and suburnbilically on the midclavicular line, and
a 5 m m trocar was placed in the anterior axillary line.
T h e line of Toldt was incised and the ascending colon
was reflected medially to expose the kidney. The cyst
was readily identified by the characteristic “blue
dome” in Gerota’s fascia. T h e fascia and perirenal fat
were dissected from the cyst. An 18G needle was used
to puncture and drain the cyst, and the fluid was sent
for cytological analysis. T h e cyst wall was then cir-
cumferentially excised and sent for histologic evalua-
tion, and the interior of the cyst was carefully
inspected macroscopically. T h e cyst was left open to
drain into the peritoneal cavity. A Penrose drain was
introduced through the 5mm port and placed under
laparoscopic guidance. T h e total surgical time was 2
hours, and the estimated blood loss was about 30mL.
T h e nasogastric tube was removed and the patient
advanced to a regular diet on the fourth postoperative
day. T h e postoperative period was uneventful, the
right flank pain disappeared and he was discharged on
the twelfth postoperafive day. T h e final pathological
report confirmed a benign cyst wall, and a postopera-
tive C T revealed the disappearance of the renal cyst
(Fig. 1B).

212 091 9-81 72/97/0402-0212/US$03.00 0 JUA/CLJ 1997

Laparoscopic Unroofing of Renal Cysts
Fig. 1 . Abdominal CT of case 1 . (A) Preoperative abdominal
CT shows a 6.5 cm cyst extending from the anterior aspect of
the right kidney. (B) Postoperative CT reveals the disappear-
ance of the renal cyst.
Case 2
A 56-year-old woman presented with right flank pain.
Kidney, ureter and bladder intravenous pyelogram,
(IVP) and C T (Fig. 2A, B) revealed right hydrone-
phrosis due to an impacted stone at the right
ureteropelvic junction, poor excretion of the left kid-
ney, and a left huge simple renal cyst with gall stones.
After fragmentation of the right renal stone with
ESWL treatment, laparoscopic unroofing of the left
renal cyst and cholecystectomy were performed.
T h e patient was placed in the hemi-decubitus posi-
tion, and general endotracheal anesthesia obtained. A
Hasson cannula was positioned in the superior crease
of the umbilicus. Two 11 mm ports were placed 5 cm
below the scaphoid process and 3 cm below the costal
margin on the right midclavicular line. After the
cholecystectomy, two 11 m m ports were placed 2 cm
below the costal margin and subumbilically on the left
midclavicular line. A 5 m m trocar was also placed in
the left anterior axillary line during this procedure.
Laparoscopic inspection revealed a large mass extend-
ing through the mesentery of the descending colon.
H. Mimata et al.
Careful dissection through the mesocolon was per-
formed, avoiding injury to the marginal colic arteries.
T h e blue wall of the cyst was easily visible, and aspi-
ration obtained straw-colored fluid. T h e cyst wall was
resected with elcctrosurgery dissecting scissors and
sent for frozen section examination. After confirma-
tion of the benign nature of the cyst wall and
hemostasis was verified, all ports were removed. The
total operative time was 2 hours and 40 minutes, but
surgery for the renal cyst required only 1 hour. The
estimated blood loss was about 45mL. The patient
was bcgun on a regular diet on the first postoperative
day and discharged on the eighth postoperative day.
There was prompt excretion of the left kidney
postoperatively on-an IVP (Fig. 2C) and a C T (Fig.
2D) confirmed the disappearance of the renal cyst.
Case 3
A 55-year-old female complained of dull pain in
her right flank. An IVP revealed right mild
hydronephrosis (Fig. 3A), and sonography and a C T
scan (Fig. 3B) revealed a right renal cyst with thin
septations which were not enhanced after an intrave-
nous injection of contrast medium. Aspiration of the
cyst revealed a yellowish fluid and the cytology was
negative. T h e patient continued to experience right
flank pain and was referred to our hospital. Due to the
indeterminate nature of the renal cyst, we performed
laparoscopic unroofing using a retroperitoneal
approach.
After general endotracheal anesthesia was obtained
and the stomach and bladder intubated, the patient
was placed in the left lateral decubitus position with
the surgeons and assistants positioned on the right
side of the table. A 3 cm incision was made 1 cm below
the umbilicus on the posterior axillary line. The exter-
nal and internal oblique abdominal muscles and the
transverse abdominalis were divided bluntly. The
peritoneum was dissected medially from the abdomi-
nal wall and a Hasson cannula inserted into a working
space created with an index finger. CO, insufflation at
a pressure of 1 2 m m H g was used to maintain the
working space in the retroperitoneal cavity. On the
anterior axillary line, 5 and 10 mm trocars were placed
1 cm below and 5 cm above the umbilicus, respec-
tively. A working space within the retroperitoneal fat
was developed using grasping forceps, and an addi-
tional 5 m m trocar was placed on the midclavicular
line below the umbilicus. Gerota’s fascia was incised
and opened. The kidney was identified and dissected
from the perinephric fatty tissue. After recognizing the
cyst wall, aspiration by a, 14G needle was performed
from the anterior abdominal wall. T h e cyst wall was
resected with electrosurgery dissecting scissors and
sent for pathological examination of a frozen section.
T h e cyst was multiply-septated with thin walls and
213
Int J Urol 1997;4:212-218

Fig. 2. IVP and CT scans from case 2. (A) Preoperative IVP shows right hydronephrosis, an impacted stone at the right
ureteropelvic junction and poor excretion of the left kidney. (B) Preoperative CT shows a large left renal cyst and right
hydronephrosis. (C) Postoperative IVP shows right mild hydronephrosis with prompt excretion of the left kidney. (D)
Postoperative CT shows the disappearance of the left renal cyst.

diagnosed as a multilocular renal cyst during the pro-
cedure (Fig. 4). T h e interior and base of the lesion
were thoroughly inspected, and reviewed with the
pathologist before completing the procedure. After
hemostasis was verified, the port sites were closed.
The laparoscope was frequently obscured by bleeding
from the trocar port making the procedure very diffi-
cult and time-consuming. T h e total surgical time was
5 hours and the estimated blood loss was about
60 mL. T h e patient was begun on a regular diet on the
first postoperative day and discharged on the 18th
postoperative day. An IVP and C T (Fig. 5A, B)
showed disappearance bf the right hydronephrosis,
but a small renal cyst still remained 3 months after the
procedure, however, by 1 year, the cyst disappeared
(Fig. 5C).

214
laparoscopic Unroofing of Renal Cysts H . Mimata et a!.

cated cystic lesions. Some of these lesions are benign,

such as multiloculated cystic nephromas,
multiloculated cysts, hemorrhagic cysts, complex
septated cysts, and chronically-infected or calcified
cysts, while some will be malignant, such as cystic
renal cell carcinomas. Category IV lesions are clearly
malignant lesions with large cystic components.
These lesions show irregularity of margins and have
solid vascular elements.
Simple renal cysts (Bosniak category I) are com-
mon and do not usually require the rap^.^ Indications
for therapy include pain, hematuria, hypertension,
recurrent infection or obstructive uropathy.
Percutaneous aspiration and sclerosis is recom-
mended as the primary therapy for symptomatic sim-
ple renal cysts.'J Although highly successful in the
short-term, this method is limited in that the rate of
recurrence with large cysts is 54% and significant
complications have been reported including perirenal
hemorrhage, arteriovenous fistula, infection and
ureteropelvic stricture. Endoscopic marsupialization
has been attempted by several authors as minimally-
invasive surgery, while percutaneous resection and
fulguration are applicable to peripheral cysts,'O and
retrograde marsupialization with flexible uretero-
nephroscopy is technically difficult and applicable
only to peripelvic renal cysts.'I Recently, laparoscopic
marsupialization of a simple renal cyst was reported to
be a safe and effective alternative to open surgery for
patients who have failed conservative measure^.^-^ Al-
though peripheral cysts do not normally require a
laparoscopic approach as these cysts are routinely
managed successfully by cyst aspiration and
sclerosing, we used a laparoscopic approach in case 1
where the large cyst protruded from the anterior as-
pect of the kidney. The laparoscopic approach was
done because the location of the cyst along the ante-
rior aspect of the kidney increased the incidence of

Fig. 3. Preoperative scans of case 3. (A) IVP shows right mild

hydronephrosis, and ( 8 ) the CT shows mild hydronephrosis
and a cyst which contains a small structure in the right
kidney.

DISCUSSION
Bosniak classified renal cysts into 4 categories.' Cat-
egory I lesions, which are the most common, are
uncomplicated, simple benign cysts of the kidney de-
finitively diagnosed by sonography andlor C T . Cat-
egory I1 lesions are minimally-complicated benign
cysts but have some radiologic findings that cause
concern. These lesions septated Fig. 4. Laparoscopic view of case 3 showing the septations
minimally-calcified cysts, infected cysts, and high- of the renal cyst which confirmed a diagnosis of a
density cysts. Category 111 lesions are more compli- multilocular renal cyst.

215
Int J Urol 1997;4:212-218
Fig. 5 . Postoperative scans from case 3. (A) An IVP shows the disappearance of the right hydronephrosis, and (8) the CT shows
disappearance of the right hydronephrosis, but a small renal cyst still remains. (C) CT scan at 1 year after surgery showing that
the cyst has disappeared.
perirenal hemorrhage as the needle was introduced
through the entire thickness of the renal parenchyma,'
which resulted in a higher risk of tearing the renal
parenchyma.
Recently, Bellman et al.'l reported the laparoscopic
evaluation of complicated renal cyst using a
transabdominal approach. T h e authors believed that
the procedure alleviated patient anxiety concerning
the nature of the lesion and obviated years of
radiologic surveillance. But several authors have pro-
posed that strict criteria must be used in selecting
patients for laparoscopic cyst ablation in order to
minimize the incidence of unsuspected malignancy.'
Although the incidence of carcinoma within the walls
of a simple cyst is rare, and appears in the literature
primarily as single case reports, Rubenstein et al. re-
ported 2 cases of malignancy in 10 patients who
underwent laparoscopic ablation of a renal
Preoperative radiological findings must be carefully
examined to diagnose a simple renal cyst, ahd
laparoscopic marsupialization using a transabdominal
approach is contraindiaated in complicated renal cysts
due to the potential for tumor cell spillage.
216
Multilocular renal cysts have distinctive bimodal
age and sex distribution^.'^^'^ In males, 88% of the
lesions present in the first 3 years of life, whereas in
females 37% present between 10 months and 15 years
of age, while 63% presented between 31 and 69 years,
predominately in the fifth and sixth decades. Al-
though these lesions are generally benign, in some
cases, the multilocular mass contains foci of
nephroblastoma, sarcoma, or renal cell carcinoma.
Nonetheless, after careful radiological distinction
from other potentially dangerous segmental renal le-
sions (particularly Wilms tumor and neuroblastoma
in children), multilocular cysts require no specific
therapy or, at most, partial n e p h r e ~ t o m y . 'Partial
~
resection of the multilocular cysts was performed in
case 3 in this study to resolve dull flank pain and mild
hydronephrosis. Although pathological findings
showed no malignancy and the remaining cyst disap-
peared after 1 year, careful follow-up is essential in
these cases.
T h e retroperitoneal approach was attempted for
laparoscopic renal surgery using balloon dissection of
the perinephric space. Lund et a1.I6 recommended
Laparoscopic Unroofing of Renal Cysts
Gauer’s method17 for the retroperitoneal approach to
renal cysts, but we declined to use this method for fear
of rupture of the renal cysts during inflation of the
balloon. Several authors have reported using a
retroperitoneal approach for simple renal ~ y s t s , but
~-~
only Hoenig et al. used the balloon dissection
r n e t h ~ d This
. ~ method remains to be proven as a safe
procedure for the retroperitoneal unroofing of renal
cysts.
In order to decrease the recurrence rate after
laparoscopic renal cyst ablation, it has been recom-
mended that the interior cyst wall should be
electrofulgurated, coagulated with an argon beam la-
ser or covered :with perirenal fat or o m e n t ~ mHow-
.~
ever, we left the cyst open to drain into the peritoneal
cavity, as suggested by Asbury and Albala.4 Although
no complications were observed in our cases, the
safety and efficacy of opening the cyst into the
peritoneal cavity remains to be determined.
REFERENCES
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2. Bean WJ. Renal cysts: treatment with alcohol. Radiol-
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WW, Vancaillie TG, Kavoussi LR. Laparoscopic abla-
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ration. J Urol 1994;151:214A.
5. Hoenig DM, Leveillee RJ, Amaral JF, Stein BS.
Laparoscopic unroofing of symptomatic renal cysts:
EDITORIAL COMMENT
The authors present the results of transperitoneal
laparoscopic unroofing in 2 patients with a simple
renal cyst, and retroperitoneal laparoscopic unroofing
in 1 patient with complicated renal cysts. The pro-
cedure of laparoscopic unroofing is described, and the
indications for the transperitoneal and retroperitoneal
approaches are discussed. The authors stated that
they use the laparoscopic approach as first-line
therapy for large cysts on the anterior aspect of the
kidney. They conclude that transperitoneal laparo-
scopic unroofing should only be used for simple renal
cysts. They also state that complicated renal cysts may
be indicated for the retroperitoneal approach if
preoperative examinations rule out the possibility of
malignancy.
Presently, there are few indications for treating a
renal cyst (pain, hydronephrosis, and hypertension).
In most cases, percutaneous drainage of the cyst, cy-
tology of the aspirated fluid, and sclerotherapy are
H. Mimata et al.
three distinct surgical approaches. J Endourol 1994;9:
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Extraperitoneal endoscopic surgery for benign renal
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7. Munch LC, Gill IS, McRoberts JW. Laparoscopic
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nal cysts. Radiology 1986;158:1-10.
9. Laucks SP Jr, McLachlan MSF. Aging and simple cysts
of the kidney. Br J Radio1 1981;54:12-14.
10. Gelet A, Sanseverino R, Martin X, Leveque JM,
Dubernard JM. Percutaneous treatment of benign renal
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11. ICavoussi LR, Clayman RV, Mikkelsen DJ, Meretyk S.
Ureteronephroscopic marsupialization of obstructing
peripelvic renal cysts. J Urol 1991;146:411-414.
12. Bellman GC, Yamaguchi R, Kaswick J. Laparoscopic
evaluation of indeterminate renal cysts. Urology 1995;
45: 1066-1070.
13. Madewell JE, Goleman SM, Davis CJ Jr, Hartman DS,
Feigin DS, Lichtenstein JE. Multilocular cystic
nephroma: a radiologic-pathologic correlation of 58 pa-
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14. Baldauf MC, Schulz DM. Multilocular cyst of the kid-
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16. Lund GO, Winfield HN. Laparoscopic management.
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laparoscopic nephrectomy: initial case report. J Urol
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the initial steps, which can be done under local
anesthesia. The complications of this technique can
be decreased by using tetracycline as a sclerosant in-
stead of alcohol. Thus, there may be only 2 indica-
tions for laparoscopic unroofing at present: (1)
symptomatic recurrence of simple cysts after
percutaneous sclerotherapy, and (2) complicated re-
nal cysts with a low possibility of malignancy on
preoperative examination.
The authors state that laparoscopic mar-
supialization via the transabdominal approach is
contraindicated for complicated renal cysts because of
the possibility of spillage of tumor cells. However,
they cited a paper by Rubenstein et al., who found
renal cell carcinoma in 2 out of 10 simple renal cysts,
suggesting that the possibility of malignancy is high
even for simple cysts. Therefore, it seems that all
renal cysts should be treated by retroperitoneal
laparoscopic unroofing.
217
Int J Urol 1997;4:212-218
The authors performed laparoscopic unroofing via
the retroperitoneal approach without using balloon
dissection in case 3 . However, they reported that the
laparoscope was frequently obscured by bleeding
from the trocar port and the total operating time was
prolonged to 5 hours in this case. It is commonly
known that gentle inflation of a balloon (500 to
700mL) is associated with minimal risk of rupturing
renal cysts. In addition, balloon dissection provides a
AUTHOR'S REPL Y
We routinely use minocycline for percutaneous drain-
age and sclerosing peripheral renal cysts. Although no
complications were observed in patients treated with
minocycline, only 45% of renal cysts disappeared.'
Due to the low success rate with minocycline and an
increased number of complications associated with
the puncture of large renal cysts on the anterior aspect
of the kidney, we chose a laparoscopic unroofing pro-
cedure for these cysts. As the operation was techni-
cally easier and required less surgical time the renal
cysts were approached transperitoneally.
Rubenstein et al. reported 2 carcinomas in 10 sim-
ple renal cysts. Their diagnostic criteria for a
laparoscopic approach for simple renal cysts included
lesions that clearly met ultrasound or C T criteria,
while laparoscopic unroofing was performed in our
patients based on both ultrasound and CT findings.
While we recognize the presence of such anecdotal
cases, this reported malignancy rate of 20% is very
high, particularly since we have never experienced
such a case treated by open surgery, percutaneous
sclerotherapy and laparoscopic unroofing. It is pos-
218
wider operating field and makes treatment easier.
Thus, balloon dissection should probably be em-
ployed for retroperitoneal laparoscopic unroofing of
renal cysts.
Kazuo Suzuki, M D
Department of Urology
Hamamatsu University School of Medicine
Hamamatsu, Japan
sible that advances in C T scanners and diagnostic
imaging techniques have improved the identification
of soloid renal lesions, such that lesions considered
malignant in earier studies may have been incorrectly
classified due to the lower resolution of the available
CT scanners.2
The authors are not aware of reports concerning
the safety of balloon dissection for large renal cysts
and future studies should be directed at validating the
safety of this procedure for renal cysts greater than
5cm in diameter.
1. Terada K, Mizoguchi H, Imagawa M, Ogata J.
Ultrasound-guided renal cyst puncture and rninocycline-
HCl instillation. Nishinihon J Urol 1992;54: 1545-1 548.
2. Bellman GC, Yamaguchi R, Kaswick J. Laparoscopic
evaluation of indeterminate renal cysts. Urology 1995;
45:1066-1070.
Hiromitsu Mimata, M D
Department of Urology
Oita Medical University
Oita, Japan