Transperitoneal laparoscopic radical and partial nephrectomy in patients with cirrhosis: report of three cases

Introduction: Surgical stress in patients with liver disease is associated with hepatorenal syndrome, coagulopathy, encephalopathy, sepsis, ARDS, and abnormalities of volume and electrolytes. These risks as well as the surgical difficulties associated with portal hypertension, varices, ascites, and thrombocytopenia limit the treatment options available to cirrhotic patients with renal masses. The decreased stress of laparoscopy may benefit patients with significant liver disease. Methods: We performed a retrospective chart review of three patients with cirrhosis and renal masses who underwent laparoscopic renal surgery. Results: The mean patient age was 56 years old. Two patients had Child-Pugh class B cirrhosis and one had Child-Pugh class A cirrhosis. Two hand-assisted laparoscopic radical nephrectomies and one laparoscopic partial nephrectomy were performed via a transperitoneal approach. Relevant data for the radical nephrectomies includes: mass size 4.5 cm and 4.0 cm, operative time 145 and 230 minutes, estimated blood loss 25 cc and 150 cc, and postoperative hospitalization of 4 and 3 days, respectively. Data for the partial nephrectomy includes: mass size 1.3 cm, operative time 130 minutes, estimated blood loss 50 cc, and postoperative hospitalization of 2 days. No case required open conversion nor suffered postoperative complications. Final pathology revealed clear cell renal cell carcinoma, stage pT1a, Fuhrman grade 214 in two patients and sarcomatoid renal cell carcinoma, stage pT1b, Fuhrman grade 414 in one patient. Intraoperative findings included thickened peritoneum with dense vascular adhesions due to chronic ascites. Platelets and fresh frozen plasma were administered intraoperatively during the partial nephrectomy to prevent bleeding. A peritoneal drain was placed during one of the radical nephrectomies for postoperative monitoring of ascites volume. Conclusions: Patients with cirrhosis and a renal mass represent challenging cases. With careful patient selection and management in conjunction with their hepatologist, laparoscopic renal surgery can be performed safely by experienced laparoscopists.