Laparoscopic cyst decortication in autosomal dominant polycystic kidney disease: impact on pain, hypertension, and renal function.
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.
Lee
David I
DI
Department of Surgery, Division of Urologic Surgery, Washington University School of Medicine, St. Louis, Missouri, USA.
Andreoni
Cassio R
CR
Rehman
Jamil
J
Landman
Jaime
J
Ragab
Maged
M
Yan
Yan
Y
Chen
Cathy
C
Shindel
Alan
A
Middleton
William
W
Shalhav
Arieh
A
McDougall
Elspeth M
EM
Clayman
Ralph V
RV
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
D000700:Analgesics; D003404:Creatinine