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JOURNAL OF LAPAROENDOSCOPIC & ADVANCED SURGICAL TECHNIQUESVolume 15, Number 3, 2005© Mary Ann Liebert, Inc.

Laparoscopic Nephroureterectomy for Tuberculous Nonfunctioning Kidneys Compared with Laparoscopic Nephroureterectomy for Other Diseases

PERCY JAL CHIBBER, FRCS, MNAMS, HEMENDRAN N. SHAH, MCh, DNB, and PRITESH JAIN, MS

ABSTRACT

Objective: To summarize the results of 8 consecutive laparoscopic nephroureterectomies (LNUs)for tuberculous nonfunctioning kidneys and compare them with 10 LNUs performed for other be-nign etiologies (control group).

Materials and Methods: From November 1999 to February 2004, 8 patients underwent LNU fortuberculous ureteric stricture with a nonfunctioning kidney at our center. During the same time pe-riod, 10 LNUs were performed for other benign conditions. Hospital records were reviewed to ob-tain demographic data. In addition, operative time, intraoperative and postoperative complications,duration of postoperative ileus, and hospital stay was recorded. The outcomes of surgery for tu-berculosis were compared with that for the control group. Patients were followed up for long-termcomplications of laparoscopic surgery.

Results: The two groups had a comparable demographic data. Nephroureterectomy was success-fully performed laparoscopically in all 8 patients with tuberculosis. One patient in the control group,with a large staghorn renal and ureteral calculus, required conversion to open surgery due to denseperinephric adhesions. The outcome of surgery for tuberculosis was compared with outcomes in thecontrol group using SPSS software. The mean operative time, blood loss, analgesic requirement, du-ration of postoperative ileus, and hospital stay of both groups was comparable, and the differencesbetween them were statistically insignificant.

Conclusion: The results of this study indicate that LNU for a tuberculous nonfunctioning kidneyis a safe, effective, and less invasive treatment modality. Comparing our results with those ofnephroureterectomy for other, benign diseases shows that the procedure has similar safety and ef-ficacy even for tuberculous kidneys. Tuberculosis should not be considered a contraindication fora laparoscopic approach. Laparoscopic nephroureterectomy should be offered as the treatmentmodality of choice to all patients with tuberculous nonfunctioning kidney whose disease involves thekidney and ureters.

Department of Urology, Sir J. J. Hospitals and Grant Medical College, Mumbai, India.

NEPHROURETERECTOMY FOR TUBERCULOUS KIDNEY 309

INTRODUCTION

LAPAROSCOPY HAS BEEN EXPANDING in technical ex-pertise, instrumentation, and surgical stature since its

inception. Most of the ablative and reconstructive surg-eries in urology can be accomplished with the laparo-scope. The procedure is minimally invasive, with lessmorbidity, more rapid postoperative recovery, and un-compromised surgical endpoints as substantiated by fol-low-up outcome data.

Since the first clinical report in 1991, laparoscopicnephrectomy has been embraced by urologists world-wide.1 At many medical centers, including ours, laparo-scopic nephrectomy has replaced open nephrectomy as atreatment of choice for many benign and malignant dis-eases with excellent results.

Advanced renal tuberculosis is known to cause non-functioning hydronephrotic kidneys, caseation, and cal-cification. Management of nonfunctioning or severelydiseased tuberculous kidneys and nephrectomy for re-moval of a potentially dangerous organ is mandatory.2

However, dense perinephric adhesions and a high con-version rate remain a relative contraindication, and theapplication of the laparoscopic technique for nephrec-tomy in tuberculous kidneys continues to be a technicalchallenge.3

We analyzed our data on 8 patients who underwentlaparoscopic nephroureterectomy (LN) for tuberculousnonfunctioning kidney and compared them with the re-sults of LNU for other benign conditions.

Although nephroureterectomy is rarely indicated in tu-berculosis, our goal was to remove as much diseasedureter as possible with the kidney. This helps to maxi-mize the removal of foci of tuberculosis and allow thechemotherapeutic drugs to destroy the residual myco-bacterium.

MATERIALS AND METHODS

From August 1999 to February 2004, 18 patients un-derwent LNU for benign diseases that caused nonfunc-tioning kidneys. Of these, 8 patients had renal and ureteraltuberculosis and the remaining 10 patients had other be-nign diseases causing nonfunctioning kidneys. This lat-ter group served as the control group.

Tuberculosis group

Tuberculosis was suspected based on symptoms andconfirmed by a positive urine smear for acid-fast bacilli,urine polymerase chain reaction for acid-fast bacilli, in-travenous urography and/or histopathologic evaluation ofbladder biopsy. Four of the 8 patients had hydro-ureteronephrosis affecting the other kidney due to in-

volvement of the ureterovesical junction (reflux or ob-struction). These 4 patients had raised creatinine (mean,2.9 mg/dL; range, 2.1–4.8 mg/dL) and underwent ante-grade or retrograde ureteral stenting.

All patients received antituberculosis treatment beforesurgery. The standard regimen consisted of 4 drugs in theinitial 2 months: isoniazid 5mg/kg orally once daily, ri-fampicin 10 mg/kg orally once daily, pyrazinamide 25mg/kg orally in 2 divided doses daily, and ethambutol 15mg/kg orally once daily. In the remaining 6 to 10 months,isoniazid and rifampicin were administered daily in thesame doses.

Five of the 8 nephrectomized kidneys had a percuta-neous nephrostomy inserted to drain the obstructed andinfected renal units. Severely diseased kidneys with�10% relative function on the diethylenetriaminepen-taacetic acid scan or � 5 mL/minute creatinine clearanceon nephrostomy drainage despite intensive chemotherapywere considered nonfunctioning, and scheduled fornephrectomy.

Control group

Ten consecutive LNUs were performed during thesame period for benign etiologies other than tuberculo-sis and were defined as a control group. The causes offunctional loss in the control group are listed in Table 1.

Operative technique

The initial cases in both groups were carried outtransperitoneally and later on with increasing experiencewe switched to the retroperitoneal approach. In the tu-berculosis group, 5 LNUs were performed by thetransperitoneal approach and 3 using the retroperitonealapproach. In the control group, 6 procedures were ac-complished transperitoneally and 4 retroperitoneally. Allpatients were started on appropriate culture-specific an-tibiotics 1 to 2 days preoperatively in order to sterilizethe urine prior to nephrectomy. Patients received a fullmechanical bowel preparation with Golytely the day be-fore surgery. The percutaneous nephrostomy tube in-serted preoperatively in 5 patients was not changed priorto the nephrectomy.

TABLE 1. INDICATIONS FOR LAPAROSCOPIC

NEPHROURETERECTOMY IN THE CONTROL GROUP

Numberof

Cause of nonfunctioning kidney patients

Impacted ureteric calculus 4Reflux nephropathy 2Obstructed megaureter 1Ureteric occlusion following gynecologic surgery 3

310 CHIBBER ET AL.

Transperitoneal laparoscopic nephrectomy was per-formed according to the technique described by Des-grandchamps et al.4 In the retroperitoneal approach, theretroperitoneal space was dissected using the balloontechnique as described by Gaur.5 The balloon was placedoutside Gerota’s fascia due to fewer adhesions and scar-ring in this area compared to within Gerota’s fascia. Inboth approaches, the standard three ports were used: a10-mm camera port and two working ports, of 10 mmand 5 mm. The renal hilar dissection was accomplishedfirst and the renal hilar vessels were separately securedwith Ligaclips 10-mm titanium clips (Ethicon Endo-surgery, Cincinnati, Ohio).

After adequate dissection of vessels, three clips wereplaced on the patient side of vessel and two clips wereplaced on the specimen side. The kidney was dissectedwith the surrounding Gerota’s fascia left intact, as ide-ally done during radical nephrectomy. During dissectionof the upper pole, the Gerota’s fascia was incised, andthe adrenals were preserved in all cases. We found thatdissecting the kidney within the Gerota’s fascia was dif-ficult due to the presence of dense perinephric adhesionsin most cases. If present, the percutaneous nephrostomytube was removed after dissecting the kidney at the levelof the nephrostomy tube entry. The thick walled ureterwas dissected safely as far distally as possible. Dissec-tion was possible below the level of bifurcation of thecommon iliac artery in all the cases. The specimen wasdelivered intact through a low Pfannensteil incision andsent for histopathologic examination.

At the end of the procedure a drain was kept in all thepatients. A nasogastric tube that was inserted at the startof the procedure was removed at the end of surgery inall the patients.

Early ambulation and oral intake were encouragedafter 12 hours. The drain was removed within 48 hoursin all the patients. Various parameters were analyzed,including operative time, estimated blood loss, re-sumption of oral intake, analgesic requirement, anddischarge from the hospital. Statistical analysis wasperformed using the two-tailed t-test (SPSS Software,Chicago, Illinois). Differences were considered sig-nificant at P � 0.05.

RESULTS

The two groups had comparable demographic data. Inthe tuberculosis group, 8 patients (6 men and 2 women)underwent LNU for unilateral nonfunctioning kidney sec-ondary to renal and ureteral tuberculosis. The mean agewas 47.5 years (range, 22–64 years), and LNU was suc-cessfully performed in all 8 patients.

The control group consisted of 7 men and 3 womenwith a mean age of 38.5 years (range, 12–50 years). Onepatient with a nonfunctioning kidney secondary to a largestaghorn renal and ureteral calculus required conversionto open surgery due to the presence of dense perinephricadhesions.

The mean operative time, blood loss, analgesic re-quirement, duration of postoperative ileus, and hospitalstay was comparable and the difference between the twogroups was statistically highly insignificant (Table 2).

DISCUSSION

Tuberculosis is a major public health problem in de-veloping nations. The kidney and possibly the prostateare the primary sites of tuberculous infection in the gen-itourinary tract. In advanced cases irreversible renal dam-age is common, with complete replacement of renalparenchyma with caseation, fibrosis, and calcification.The wall of the renal pelvis and ureter are thickened withsignificant perinephritis and periureteritis. Ureteral steno-sis may be complete, causing autonephrectomy. Such akidney is fibrosed and functionless. Flechner and Gowrecommended that nonfunctioning kidneys be removedafter 1–2 months of medical therapy, since it may not bepossible to eradicate the infection without nephrectomy,and up to half of all cases of renal tuberculosis may re-quire such a radical procedure.6

Since its first description by Clayman et al., laparo-scopic surgery has made tremendous progress in urol-ogy.1 The retroperitoneoscopic technique was further refined by Gaur et al. with the introduction of retroperi-toneal dissection using the balloon technique.5 In viewof dense perinephric inflammation and adhesions that de-

TABLE 2. COMPARISON OF TUBERCULOSIS AND CONTROL GROUPS

Tuberculosis group Control group P valuea

Mean operative time (minutes) 208.5 (range, 150–268) 209.6 (range, 40–256) 0.949Mean blood loss (mL) 326.25 (range, 180–700) 213 (range, 100–560) 0.173Conversion to open surgery 0 1 0.163Mean resumption of oral intake (hours) 16.75 (range, 12–28) 19.2 (range, 12–30) 0.375Mean analgesic requirement (mg of diclofenac sodium) 225 mg 225 mg 1.000Mean hospital stay (days) 2.62 2.5 0.701

aTwo-tailed t-test.

NEPHROURETERECTOMY FOR TUBERCULOUS KIDNEY 311

velop in tuberculous kidneys, laparoscopic nephrectomywas considered relatively contraindicated. Gupta et al.presented a case of tubercular pyelonephritic nonfunc-tioning kidney which was difficult to mobilize during la-paroscopy due to dense perinephric adhesions, and sub-sequently was converted to an open nephrectomy.7 Theyspeculated that dissection of a tuberculous kidney isfraught with potential complications such as leakage ofcaseous material into the peritoneal cavity and systemicdissemination of the disease. However, surgical situationsthat would have been regarded as contraindicated only afew years ago are now accepted as proper indications forthe laparoscopic approach because of the rapid improve-ment in laparoscopic instruments and surgical skills. Kimet al. described their experience with 13 laparoscopicnephrectomies for nonfunctioning tuberculous kidneys,with a success rate of 92% and a mean operative timewas 268 minutes.8 They experienced some difficulties inreleasing the adhesions, with no significant intraopera-tive or postoperative complications. Based on their ex-perience they recommended that tuberculosis should notbe a contraindication for a laparoscopic approach. Hemalet al. compared retroperitoneal nephrectomy with opensurgery for tuberculous nonfunctioning kidney.9 Duringtheir initial study, the retroperitoneal space was dissectedby placing a balloon inside Gerota’s fascia. The kidneywas dissected first, with hilar dissection at the end. How-ever, they encountered significant difficulty with per-inephric dissection of the kidney, with significant oozingfrom the dissected kidney. Learning from their initial ex-perience they subsequently modified their technique. Theballoon was placed outside Gerota’s fascia to create aretroperitoneal space. After controlling the hilum, thekidney was dissected mostly outside Gerota’s fascia.Staying outside the fascia helps because scarring and ad-hesions are less in this area than within the fascia. Theydissected the ureter as low as possible to performnephroureterectomy in cases where there was evidenceof disease in the ureter. In their series of 9 cases, 2 cases(22%) required conversion to open surgery. There wasinadvertent renal puncture during dissection, with leak-age of caseous material, in 2 patients. It was managed bysaline washing at the end of the procedure and had no untoward effect at follow-up more than 6 months postoperatively. In comparing their retroperitoneoscopywith open surgery they found all the advantages of laparoscopy over open surgery. Lee et al. compared lap-aroscopic nephrectomy for tuberculous nonfunctioningkidney with that for other disease and found that the twogroups showed comparable perioperative and postopera-tive parameters, except for longer mean operative timein the laparoscopy group.10

In the present study we tried to compare the results ofLNUs for tuberculous nonfunctioning kidney with thosefor benign nontuberculous cases to evaluate the efficacyof this approach to the tuberculous kidney. Based on ourfindings of similar perioperative and postoperative sur-gical variables, we suggest that LNU should be offeredto all patients with tuberculous nonfunctioning kidney.The application of LNU for the tuberculous nonfunc-tioning kidney can result in the same reduced level ofmorbidity as achieved by LNU for other diseases.

REFERENCES

1. Clayman RV, Kavoussi LR, Soper NJ, et al. Laparoscopicnephrectomy: initial case report. J Urol 1991;146:278–282.

2. Gow JG. Genitourinary tuberculosis. In Walsh PC, RetikAB, Vaugn ED Jr, Wein AJ, eds. Campbell’s Urology, 8thed. Philadelphia: Saunders, 2002:807–836.

3. Rassweiller J, Fornara P, Weber M, et al. Laparoscopicnephrectomy: the experience of the laparoscopy workinggroup of the German Urologic Association. J Urol1998;160:18–21.

4. Desgrandchamps F, Gossot D, Jabbour ME, Meria P, Teil-lac P, Le Duc A. A 3-trocar technique for transperitoneallaparoscopic nephrectomy. J Urol 1999;161:1530–1532.

5. Gaur DD. Laparoscopic operative retroperitoneoscopy: useof a new device. J Urol 1992;148:1137–1139.

6. Flechner SM, Gow JG. Role of nephrectomy in the treat-ment of non-functioning or very poorly functioning unilat-eral tuberculous kidney. J Urol 1980;123:822–826.

7. Gupta NP, Agrawal AK, Sood S. Tubercular pyelonephriticnonfunctioning kidney—another relative contraindicationfor laparoscopic nephrectomy: a case report. J Laparoen-dosc Adv Surg Tech A 1997;7:131–134.

8. Kim HH, Lee KS, Park K, Ahn H. Laparoscopic nephrec-tomy for nonfunctioning tuberculous kidney. J Endourol2000;14:433–437.

9. Hemal AK, Gupta NP, Rajeev K. Comparison of retroperi-toneoscopic nephrectomy with open surgery for tubercu-lous non-functioning kidneys. J Urol 2000;164:32–35.

10. Lee KS, Kim HH, Byun SS, Kwak C, Park K, Ahn H. Lap-aroscopic nephrectomy for tuberculous nonfunctioning kid-ney: comparison with laparoscopic simple nephrectomy forother diseases. Urology 2002;60:411–414.

Address reprint requests to:Percy Jal Chibber, FRCS

1/23, Clerk Road, Haji AliMumbai 400034

India

E-mail: percy.chibber@gmail.com