title: Laparoscopic cyst decortication in autosomal dominant polycystic kidney disease: impact on pain, hypertension, and renal function.
abstract: OBJECTIVE
  In patients with autosomal dominant polycystic kidney disease (ADPKD), laparoscopic cyst decortication (LCD) has been proposed as a means to relieve chronic cyst-related pain. We present our 7-year experience with LCD for ADPKD with regard to pain relief, hypertension, and renal function.
  
  
  METHODS
  Between August 1994 and February 2001, 29 ADPKD patients with chronic pain (N=29), hypertension (N=21), and renal insufficiency (N=10) underwent 35 LCD procedures. Every detectable cyst within 2 mm of the renal surface was treated. Pain relief was assessed using a pain analog scale; relative pain relief (RPR) equaled (preoperative pain score) - (postoperative pain score)/(preoperative pain score). Hypertension was evaluated using the antihypertensive therapeutic index (ATI): [(dose of blood pressure medication 1/max dose 1) + (dose med 2/max dose 2) + etc.] x 10. Renal function was assessed using the Cockcroft and Gault formula for creatinine clearance.
  
  
  RESULTS
  The mean operating room time was 4.9 hours (range 2.6-6.6 hours) with no conversions to open surgery. An average of 220 cysts (range 4-692) were treated per patient. The mean follow-up was 32.3 months (range 6-72 months). The RPR was 58%, 47%, and 63% at 12, 24, and 36 months, respectively. At 12, 24, and 36 months, 73%, 52%, and 81% of patients, respectively, noted >50% improvement in their pain compared with the preoperative situation. Five patients became normotensive, and patients improved their ATI by an average of 49% (range 11%-93%). However, six patients had worsening hypertension, with an ATI increase averaging 53% (range 11%-122%), and one patient who was not hypertensive preoperatively has since developed hypertension. The creatinine clearance changed +4%, +7%, and -2% at 12, 24, and 36 months, respectively. Only one patient had a >20% increase in creatinine clearance. The only patients with a >20% decrease in creatinine clearance were those who had a creatinine clearance <30 mg/dL preoperatively (average decrease 34% [range 20%-51%]).
  
  
  CONCLUSIONS
  For ADPKD patients with debilitating pain, extensive LCD can provide durable relief. In the majority of patients with pain and hypertension, a marked improvement in blood pressure also occurs. Cyst decortication was not associated with worsening renal function; indeed, renal function remained largely unchanged over the 3-year follow-up period.
authors.affiliation: Department of Surgery, Division of Urologic Surgery, Washington University School of Medicine, St. Louis, Missouri, USA.
authors.forename: David I
authors.initials: DI
authors.lastname: Lee
authors.forename: Cassio R
authors.initials: CR
authors.lastname: Andreoni
authors.forename: Jamil
authors.initials: J
authors.lastname: Rehman
authors.forename: Jaime
authors.initials: J
authors.lastname: Landman
authors.forename: Maged
authors.initials: M
authors.lastname: Ragab
authors.forename: Yan
authors.initials: Y
authors.lastname: Yan
authors.forename: Cathy
authors.initials: C
authors.lastname: Chen
authors.forename: Alan
authors.initials: A
authors.lastname: Shindel
authors.forename: William
authors.initials: W
authors.lastname: Middleton
authors.forename: Arieh
authors.initials: A
authors.lastname: Shalhav
authors.forename: Elspeth M
authors.initials: EM
authors.lastname: McDougall
authors.forename: Ralph V
authors.initials: RV
authors.lastname: Clayman
mesh_terms: D000328:Adult; D000368:Aged; D000700:Analgesics / Q000627:therapeutic use; D001363:Awards and Prizes; D016063:Blood Loss, Surgical; D003404:Creatinine / Q000378:metabolism; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D006973:Hypertension / Q000209:etiology* / Q000601:surgery; D007668:Kidney / Q000000981:diagnostic imaging; D010535:Laparoscopy / Q000379:methods*; D007902:Length of Stay; D008297:Male; D008875:Middle Aged; D010043:Outcome and Process Assessment, Health Care; D010146:Pain / Q000188:drug therapy / Q000209:etiology* / Q000601:surgery; D016891:Polycystic Kidney, Autosomal Dominant / Q000150:complications* / Q000378:metabolism / Q000601:surgery*; D011788:Quality of Life; D011877:Radionuclide Imaging; D051437:Renal Insufficiency / Q000209:etiology* / Q000601:surgery; D016896:Treatment Outcome; D014463:Ultrasonography
chemical_list: D000700:Analgesics; D003404:Creatinine