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Campbell 10th edition:

Renal Cyst Disease: Indication,


Procedure and Results
AKMAL FAWZI YUSRIL UMAM
Introduction
o Renal cysts are extremely common and are present in more than one third of patients more
than 50 years old.
o They rarely require surgical intervention, but indications include cyst-associated pain, infection,
or obstruction.
o Classification schema have been developed to help clinicians make determinations regarding
management, the most popular being the Bosniak system.
https://radiopaedia.org/articles/bosniak-classification-system-of-renal-cystic-masses
Indications
o First-line therapy and diagnosis of symptomatic renal cysts often involves percutaneous image-
guided needle aspiration, with or without the use of a sclerosing agent, to prevent recurrence.
o If recur when fluid reaccumulates, this need surgical treatment to resolve the pain.
o In addition to causing pain, cysts may compress the renal parenchyma or other adjacent
organs, cause ureteral obstruction and obstructive uropathy, spontaneously bleed, cause
hypertension, or become infected.
o Laparoscopic decortication or unroofing may be used to treat these cysts, which are typically
simple in character.
o Cysts with complex appearance, such as thickened septa, calcification, or enhancement
(Bosniak class III- IV), may be explored and sampled laparoscopically to rule out renal cell
carcinoma due to their increased risk of harboring malignancy.
o Options include cryoablation, enucleation, partial nephrectomy, or radical nephrectomy.
o A subset of patients with autosomal dominant polycystic kidney disease (ADPKD) may develop
cyst-associated pain and Laparoscopic cyst decortication, marsupialization, or unroofing can be
of benefit to these patients and success to relief pain.
o In patients with end-stage renal disease, bilateral synchronous laparoscopic nephrectomy may
be performed in patients with enlarged, symptomatic, or infected kidneys.
Procedures
o Depending on cyst location, a transperitoneal or retroperitoneal approach may be used as
previously described.
o Intraoperative ultrasonography may be used to identify the cyst or cysts in question.
o It is usually easier to dissect out the cyst wall before evacuating fluid.
o If no evidence of malignancy is seen, the remaining cyst wall may be fulgarated with either
electrocautery or the argon beam coagulator.
o If malignancy is noted, extirpative surgery or cryoablation may be used to treat the remainder
of the lesion.
oWhen treating central or perihilar cysts, it may not be feasible to remove a large portion of the
cyst wall. In these cases, it is helpful to place a pedicle of autologous fat into the defect to act as
a wick.
Results
o Laparoscopic treatment of symptomatic renal cysts has been found to be effective in both
decompression and pain control.
o In patients with ADPKD, additional benefits of cyst decortication have been noted, including
decreased blood pressure.
o the reported incidence of renal cell carcinoma in cystic lesions is between 3% and 20%.
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