Laparoscopic deroofing of simple renal cysts (interventional procedures consultation)

NATIONAL INSTITUTE FOR HEALTH AND CLINICAL EXCELLENCE

Interventional Procedure Consultation Document

Laparoscopic deroofing of simple renal cysts

Solitary cysts in the kidney are common, but rarely cause any symptoms. Multiple cysts are less common and are usually due to polycystic kidney disease, which is an inherited condition. Laparoscopic deroofing involves draining the cyst and removing part of the cyst wall, which is done through small cuts in the abdomen using a fine telescope to see inside the body ('keyhole surgery').

The National Institute for Health and Clinical Excellence is examining laparoscopic deroofing of simple renal cysts and will publish guidance on its safety and efficacy to the NHS in England, Wales, Scotland and Northern Ireland. The Institute's Interventional Procedures Advisory Committee has considered the available evidence and the views of Specialist Advisers, who are consultants with knowledge of the procedure. The Advisory Committee has made provisional recommendations about laparoscopic deroofing of simple renal cysts.

This document summarises the procedure and sets out the provisional recommendations made by the Advisory Committee. It has been prepared for public consultation. The Advisory Committee particularly welcomes:

comments on the preliminary recommendations
the identification of factual inaccuracies
additional relevant evidence.

Note that this document is not the Institute's formal guidance on this procedure. The recommendations are provisional and may change after consultation.

The process that the Institute will follow after the consultation period ends is as follows.

The Advisory Committee will meet again to consider the original evidence and its provisional recommendations in the light of the comments received during consultation.
The Advisory Committee will then prepare draft guidance which will be the basis for the Institute's guidance on the use of the procedure in the NHS in England, Wales, Scotland and Northern Ireland.

For further details, see the Interventional Procedures Programme manual, which is available from the Institute's website (www.nice.org.uk/ipprogrammemanual).

Closing date for comments: 24 April 2007
Target date for publication of guidance: July 2007

Note that this document is not the Institute's guidance on this procedure. The recommendations are provisional and may change after consultation.

1	Provisional recommendations

1.1	Current evidence on the safety and efficacy of laparoscopic deroofing of simple renal cysts is adequate to support the use of this procedure provided that normal arrangements are in place for consent, audit and clinical governance.
1.2	Patient selection for this procedure is important because most renal cysts do not cause symptoms and do not require treatment. Clinicians should take steps to predict whether deroofing is likely to relieve symptoms, usually by observing the effect of cyst aspiration. Laparoscopic deroofing should not be performed for renal cysts that are asymptomatic.

The procedure

2.1

Indications

2.1.1

Simple renal cysts typically have thin walls with no calcification, septation or enhancement shown on contrast studies. Solitary simple cysts are common and are often diagnosed incidentally. In the minority of patients who are symptomatic, pain is the most frequent complaint.

2.1.2

Symptomatic renal cysts can be managed with analgesic medication, needle aspiration (with or without administration of a sclerosant) and open surgical cyst deroofing if aspiration is unsuccessful. In some patients, a nephrectomy may be necessary. Asymptomatic cysts do not usually require any treatment.

2.1.3

Laparoscopic deroofing is not used if there is any suspicion of malignancy. (Malignancy is very rare in simple renal cysts.) There is a higher risk of malignancy in polycystic kidney disease, an inherited condition characterised by the progressive formation of many fluid filled cysts in the kidneys. The management of polycystic kidney disease is different from that of simple renal cysts.

2.2

Outline of the procedure

2.2.1

Laparoscopic deroofing of simple renal cysts may be performed using a retroperitoneal or a transperitoneal approach. In the former, a small incision is made in the back and a dissecting balloon is inserted to create a space in the retroperitoneal tissues. In both approaches, carbon dioxide insufflation is used and small incisions are made to provide access for the laparoscope and surgical instruments. Ultrasonography may be used to help locate the cyst, which is usually aspirated, and part of the cyst wall is then excised. Fat or omentum may be interposed to prevent recurrence. For more details, refer to the sources of evidence (see appendix).

2.3

Efficacy

2.3.1

In a non-randomised controlled trial of patients with symptomatic simple renal cysts, pain recurred in all five patients treated with cyst aspiration and sclerotherapy at a mean follow-up of 17 months, whereas all seven patients treated with laparoscopic deroofing were pain-free at a mean follow-up of 18 months.

2.3.2

In five case series of patients with symptomatic simple renal cysts (155 patients in total), the proportion of patients who were symptom-free ranged from 91% (41/45) after a mean follow-up of 52 months to 100% (20/20) after a mean follow-up of 6 months.

2.3.3

Four of these case series reported rates of cyst recurrence as 0% (0/13) after 6 months, 13% (3/23) after 34 months, 4% (2/45) after 39 months and 19% (7/36) after 67 months. For more details, refer to the sources of evidence (see Appendix).

2.3.4

Some Specialist Advisers expressed no concerns about efficacy. Others stated that there is a possibility that cysts may refill after the procedure. The Advisers considered patient selection to be important because not all cysts cause symptoms.

2.4

Safety

2.4.1

Four studies of patients with simple renal cysts (91 patients in total) each reported one case of haemorrhage (overall incidence 4%). In two patients the cyst excision margin bled excessively; one case required conversion to open surgery but the other was controlled by an intracorporeal suture. Self-limited retroperitoneal bleeding occurred in one patient (in whom a retroperitoneal approach was used) and reactionary haemorrhage occurred in another. One study reported that 1 of 9 patients had prolonged ileus. One study reported wound infection in 8% (2/24) of patients and urine leakage in 4% (1/24).

2.4.2

In a case series of 17 patients, a cyst wall carcinoma was identified during one procedure and an open nephrectomy was performed immediately. No findings of malignancy were reported in three other case series (of 29, 20 and 36 patients, respectively). For more details, refer to the sources of evidence (see Appendix).

2.4.3

The Specialist Advisers stated that theoretical adverse outcomes include haematuria, urinary tract infection, port site infection, urine leakage (from a parapelvic cyst), intraoperative bleeding, conversion to open surgery or nephrectomy, and injury to other internal organs or major blood vessels.

3	*Further information*
3.1	The Institute has published interventional procedures guidance on laparoscopic nephrectomy (including nephroureterectomy) (www.nice.org.uk/guidance/IPG136) and is developing a clinical guideline on chronic kidney disease, expected in September 2008. See www.nice.org.uk/page.aspx?o=ChronicKidneyDisease for further information.

Bruce Campbell
Chairman, Interventional Procedures Advisory Committee
March 2007

Appendix:

Sources of evidence

The following document, which summarises the evidence, was considered by the Interventional Procedures Advisory Committee when making its provisional recommendations.

' Interventional procedure overview of laparoscopic deroofing of simple renal cysts', February 2007.

Available from: www.nice.org.uk/ip380overview

This page was last updated: 30 March 2010