NDT Plus Advance Access originally published online on December 23, 2007
NDT Plus 2008 1(2):128; doi:10.1093/ndtplus/sfm033
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Bilateral synchronous open nephrectomy for renal tumours in patients following long-term dialysis
The Nephrology Center, Toranomon Branch Hospital Kajigaya, Kanagawa, Japan
Correspondence: E-mail: acci{at}mist.ocn.ne.jp
Sir,
During long-term dialysis, the kidney is at maximum risk for the development of renal cell carcinoma (RCC), and the occurrence of bilateral cases is not rare [1,2]. Based on previous studies, bilateral nephrectomy is no longer favoured, primarily due to increased morbidity and mortality after the management and complications of the anephric state, namely anaemia, hypocalcaemia and hypotension from dysadrenalism [3,4].
Between October 2004 and September 2005, we performed bilateral synchronous nephrectomy by a transperitoneal approach for suspected cases of RCC and spared one or both of the adrenal glands in seven patients. The patients with long-term haemodialysis periods ranging from 6.5 to 24.5 years (mean ± SD 16.2 ± 6.3) included four cases of acquired cystic disease of the kidney and three cases of autosomal dominant polycystic kidney disease in which kidney size was >20 cm. The mean kidney weight was 1677 g (mean ± SD 1677 ± 1420), mean operative time was 288 min (mean ± SD 288 ± 66) and mean estimated blood loss was 1045 ml (mean ± SD 1045 ± 66). During the convalescent period, there were no mortalities. During the follow-up period of 6 to 37 months, haematocrit, serum calcium and aldosterone were maintained from 27.5 to 34.1% (mean ± SD 32.0 ± 2.2), 9.8 to 11.6 mg/dl (mean ± SD 10.7 ± 0.8) and 2.3 to 22.3 pg/ml (mean ± SD 12.3 ± 8.3), respectively. Genetic recombinant erythropoietin derivatives were administered to six cases, and vitamin D was administered to one case after the operation. Hypotension (systolic blood pressure <100 mmHg during haemodialysis) from dysadrenalism was not noted at the end of the follow-up period. Out of the 14 specimens, there were 10 RCC, 2 oncocytoma and 4 benign complex cysts. Lung metastasis occurred in one patient, while the other six patients were asymptomatic and had no tumuor recurrence.
The results demonstrated that bilateral synchronous open nephrectomy is practical with acceptable morbidity, due to advances in medical management and surgical techniques. In the review of literature, respectable en bloc renal size on bilateral synchronous laparoscopic nephrectomy ranged from 20 to 27 cm. However, such cases can have a risk of dissemination, due to cyst disruption during circumferential mobilization and extraction of the kidney [5,6]. In order to avoid these complications, we selected long-term dialysis patients with a kidney size >20 cm. Based on the kidney size and the clinical condition, further studies are needed in order to determine the indication of bilateral synchronous open or laparoscopic nephrectomy for bilateral RCCs following long-term dialysis.
Conflict of interest statement. None declared.
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