A 35 year old gentleman came to us with the left flank pain of 15 days duration.He was also complaining of generalised malaise.There was no complaint of fever or lower urinary tract complaints.He was complaining of dull ache in flank region previously also on and off.But the intensity as per the patient was not significant enough to seek consultation from doctor.He didnt have any comorbdities.There was no prior history of undergoing urological/ surgical interevention.Physical examination revealed a large mass in the left flank. Imaging showed a large hydronephrotic kidney with papery thin parenchyma.IVP showed a non excreting kidney even after 24 hours.Urine examination was unremarkable.
We explained the patient about non functioning status of the kidney and need for nephrectomy.Initial on table drainage then followed by laparoscopic nephrectomy vis-a-vis open nephrectomy options were considered.Finally we decided to go for open surgery.The kidney intra-operatively was grossly enlarged and full of thick creamy pus.A total of 3litres of pus was drained and then subcapsular nephrectomy was performed.
The pyonephrotic kidney removal is difficult surgery in view of loss of planes with the surrounding structures.Many times we are misled by the symptoms.We assumed that this would be a simple hydronephrotic kidney and thus surgery will be easier because of maintained planes.Absence of fever or absence of perinephric stranding on CT scan led us to assume so.Laparoscopy is pyonephrotic kidney would be a difficult task and waste of time; which can add to patients morbidity.Initial drainage (before surgery) would add a lot to our management strategy. If a clear urine drains out a laparoscopic surgery would be the treatment of choice.If pus is drained then open surgery can be assorted to.
Dear Dr Ramayya,
ReplyDeleteExcellent case and good outcome for the patient. I agree with you and I keep teaching my trainees, Simple nephrectomy is never simple.
However, I have an alternate view to your thoughts that Laparoscopy is a 'waste of time' for such a case. I am sure you have been in situations where in you think it is an easy case and that would you worst night mare and on the other hand, the case you think is going to be difficult (non-functioning staghorn), and it turns out to be easy. Unless you attempt, you would not know. As long as the patient is counselled regarding the possibility of open, laparoscopy can be attempted.
With Warm Rgeards,
Amrith Rao