|Year : 2006 | Volume
| Issue : 4 | Page : 329-331
Laproscopic nephrectomy for renal tuberculosis
HK Nagraj, TA Kishore, S Nagalakshmi
MS Ramaiah Hospitals, MSRIT Post, Bangalore - 500 054, India
H K Nagraj
M.S. Ramaiah Hospitals, MSRIT Post, Bangalore - 500 054
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Context: Role of laparoscopy in nephrectomy for tuberculous kidneys. Aims: Comparative analysis of laparoscopic nephrectomy done for tuberculous nonfunctioning kidney against nephrectomy done for other causes. Settings and Design: Retrospective analysis of hospital data. Materials and Methods: Retrospective analysis of 20 cases of laparoscopic nephrectomy done in our department, which included eight cases of tuberculous nonfunctioning kidney and 12 cases done for other benign diseases. Results: Mean operative time was higher in the tuberculous group compared to the control group (116 min to 87 min). There was no difference between the two groups in terms of complications, wound infection, conversion rate, postoperative ileus and mean hospital stay. No major complications were seen in both the groups. Conclusions: Tuberculous nonfunctioning kidney can be effectively dealt laparoscopically with no increased morbidity. Surgeon should be aware of the difficulties and complications which may be encountered.
Keywords: Laparoscopic nephrectomy, nonfunctioning kidney, renal tuberculosis
|How to cite this article:|
Nagraj H K, Kishore T A, Nagalakshmi S. Laproscopic nephrectomy for renal tuberculosis. Indian J Urol 2006;22:329-31
Renal tuberculosis is a common disease seen in the developing world. Often patients present with advanced disease and with complete destruction of a renal unit. The management of nonfunctioning or severely diseased tuberculosis is indisputable and nephrectomy is mandatory. Nephrectomy facilitates removal of a large focus of mycobacteria and allows drugs to destroy residual mycobacteria. Laparoscopic approach for nephrectomy was considered as a relative contraindication previously. Presently, with increased experience in the field of minimally invasive surgery this scenario is rapidly changing.
| Materials and Methods|| |
We present a retrospective analysis of the last 20 cases of laparoscopic nephrectomy done in our center. Eight out of the 20 cases were tuberculosis etiology which was compared with the remaining 12 cases of nephrectomy performed for benign diseases. Diagnosis of tuberculosis was suspected based on symptoms and confirmed by a positive urine smear for acid-fast bacilli, culture for acid-fast bacilli or on excretory urography. Computerized tomography and bladder biopsy was done in certain cases. Excretory urography confirmed that all diseased kidneys were nonfunctioning or seriously destroyed and the function of the contralateral kidney was normal. The indication for nephrectomy was nonfunctioning renal units in the presence of positive urine acid-fast bacilli despite antituberculosis drug therapy, tubercular pyonephrosis, extensive ureteric strictures. Regular antituberculosis chemotherapy (5 mg/kg isoniazid orally once daily, 10 mg/kg rifampicin orally once daily and 15 mg/kg ethambutol orally once daily) before surgery for six weeks.
All cases were approached in a transperitoneal manner. After administration of general anesthesia, the patient is placed in flank position and pneumoperitoneum is created. Initially three ports are placed with primary port 10 mm at the umbilicus and secondary ports are placed in the subcostal and the iliac fossa. If further difficulty is encountered a fourth port is placed in the lumbar region which aids in retraction. Mean operative time, intraoperative complications, blood loss and postoperative complications and mean hospital stay was compared between the two groups.
All patients were treated with antibiotics to prevent infection until the removal of sutures and were continued on a regular antituberculosis chemotherapy out to nine months in the described doses. They returned for urine assessment to search for tubercle bacilli in the urine every month postoperatively. Liver function assessments were done every one-month postoperatively.
| Results|| |
Mean operative time was significantly higher in the tuberculous group compared to the control group (116 min to 87 min). There was no significant difference between the two groups in terms of complications, wound infection, conversion rate and postoperative ileus, wound infection and mean hospital stay. No major complications were seen in both the groups.
| Discussion|| |
Tuberculous kidneys were considered as a relative contraindication for laparoscopic nephrectomy previously. The earliest reports of laparoscopic nephrectomy for tuberculosis were by Gupta et al , where they described tuberculous pyelonephritis as a relative contraindication and high conversion rate. Rassweiler et al in their review of laparoscopic nephrectomy suggested that tuberculous kidneys have higher likelihood of conversion to open procedure. Recently, there have been a few reports of laparoscopic nephrectomy performed in tuberculous nonfunctioning kidney without any increased morbidity. Retroperitoneoscopic approach has been found superior to the open approach by Zhang et al and Hemal et al ., Laparoscopic tuberculous nephrectomies were shown to have no increased morbidity compared to other nephrectomies by Chibber et al and Lee et al .,
In our experience tuberculous kidneys consume more time than other benign nephrectomy but can be safely performed without higher complications [Table - 1]. We have encountered difficulties in our cases due to omental adhesion while approaching in a transperitoneal manner [Table - 2]. Omental adhesions if not released properly may preclude port placement and hinder the dissection [Figure - 1]A. While reflecting the colon from the Gerotas fascia, dense adhesions can cause a mesocolic rent [Figure - 1]B. Traditionally, tuberculous kidney is approached in a subcapsular plane or within the Gerota's fascia, but we preferred to dissect outside the Gerotas fascia in most of our cases as it helps in a direct approach to hilum [Figure - 2]A. There was difficulty in identifying the renal vessels due to dense adhesions and also caseous lymph nodes. To control renal vessels we found a posterior approach better as dissection is more difficult anteriorly owing to the presence of lymph nodes. This can be done using an additional instrument which lifts the lower pole of the kidney and by approaching without opening the Gerota's fascia. The renal artery can be dissected out with the aid of a blunt suction cannula. We routinely use hem-o-lock clips to tackle the hilum [Figure - 2]B. There was an instance of cutting into the caseous lymph nodes with extrusion of caseous material. Renal vessels could not be identified in two of our cases. In two of our cases where there was percutaneous nephrostomy tract, we had difficulties in dissecting the area around the track and there was also spillage of dense caseous material [Figure - 3]A. Most of the specimen was extracted out through a 5 cm groin incision. In one instance where there was tuberculous pyonephrosis there was spillage of pus while delivering of the specimen [Figure - 3]B. This patient subsequently had wound infection. There were no major complications in our laparoscopic nephrectomies. There was no evidence of local or distant dissemination in any of the cases.
Our series effectively demonstrate that tuberculous nephrectomy can be performed safely with no increased morbidity. The mean operative time may be increased due to various reasons stated above. The operating surgeon should be aware about the various difficulties he can encounter. The transperitoneal approach allows good maneuverability of the instruments in difficult dissections. Though the spillage of dense caseous materials can be dealt with effectively, the surgeon should be cautious in cases of tuberculous pyonephrosis where there can be gross spillage into the peritoneal cavity.
| Conclusions|| |
Laparoscopic approach is a feasible option for performing nephrectomy in tuberculous nonfunctioning kidneys. Transperitoneal laparoscopic approach can be used effectively with no increased morbidity. The laparoscopic surgeon should be aware of potential difficulties and pitfalls while confronting a case of renal tuberculosis.
| References|| |
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|2.||Gupta NP, Agrawal AK, Sood S. Tubercular pyelonephritic nonfunctioning kidney-another relative contraindication for laparoscopic nephrectomy: A case report. J Laparoendosc Adv Surg Tech A 1997;7:131-4. [PUBMED] |
|3.||Rassweiler J, Fornara P, Weber M, Janetschek G, Fahlenkamp D, Henkel T, et al Laparoscopic nephrectomy: The experience of the laparoscopy working group of the German Urologic Association. J Urol 1998;160:18-21. |
|4.||Zhang X, Zheng T, Ma X, Li HZ, Li LC, Wang SG, et al . Comparison of retroperitoneoscopic nephrectomy versus open approaches to nonfunctioning tuberculous kidneys: A report of 44 cases. J Urol 2005;173:1586-9. |
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|7.||Chibber PJ, Shah HN, Jain P. Laparoscopic nephroureterectomy for tuberculous nonfunctioning kidneys compared with laparoscopic nephroureterectomy for other diseases. J Laparoendosc Adv Surg Tech A 2005;15:308-11. [PUBMED] [FULLTEXT]|
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[Figure - 1], [Figure - 2], [Figure - 3]
[Table - 1], [Table - 2]
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