病例報告: 達文西腎盂囊腫切除術應用於囊腫造成之外部腎盂輸尿管接合處阻塞

 李宗霖、曹書瀚、蔡瀚宇、林友翔、張慧朗、陳建綸、侯鎮邦

 林口長庚紀念醫院 外科部 泌尿外科

Case Report: Robotics Renal Cyst Unroofing In External  Compression of Parapelvic Cyst

 Chung-Lin Lee , Shu-Han Tsao, Han-Yu Tsai,  Yu-Hsiang Lin, Phei-Lang Chang, Chien-Lun Chen, Chen-Pang Hou

Department of Urology, Chang Gung Memorial Hospital-Linko, Taiwan, Republic of China ; College of Medicine, Chang Gung University, Taiwan, Republic of China.

Background:   Parapelvic cyst-mediated extrinsic compression of the ureter-pelvic junction (UPJ) is a rare disease causing hydronephrosis and flank pain. Renal cyst unroofing would be the first treatment if cyst compression were symptomatic.

Case presentation: A 57-year-old male was referred for periodic evaluation of proper flank pain. Renal ultrasound revealed moderate hydronephrosis on the right side with microscopic hematuria. Contrast computer tomography and renal ultrasound scan confirmed the diagnosis of right renal hydronephrosis with a disproportionately dilated renal pelvis without renal stones. The diuretic phase of computer tomography revealed a para-pelvic renal cyst without communicating with the pelvis system. Conservative management was applied for two years due to mild hydronephrosis without deteriorating renal function. However, the patient's symptoms of flank pain persisted, and the diameter of the renal cyst continued to increase from 2.1 cm to 3.9 cm in two years. In addition, deterioration of renal function was detected. An abdominal CT revealed severe hydronephrosis due to external compression of the perihilar cyst. Robotic renal cyst unroofing was suggested. The robotic cyst decortication was smoothly performed using the da Vinci Si. Port placement included three 8mm trocars at the mid-axillary line, an assistant port 12mm at the umbilicus, and another 5 mm port for liver traction. Following the taking down of the colon and Kocher maneuver, the parapelvic cyst was in the caudal position beneath a branch of the renal vein and bulging of the renal pelvis above the same vessel. Da Vinci provided excellent visualization, which helped to distinguish parapelvic cysts from hydronephrosis. After decortication of the renal cyst, hydronephrosis rapidly subsided, and there was no more extrinsic compression of the UPJ. The branch of the renal vein was considered a non-obstructing vessel anterior to the renal pelvis. The console time was 70 min. One month after the operation, renal ultrasound was followed, showing that the patient's hydronephrosis had disappeared and the patient became symptom-free.

Conclusion:

Robotic para-hilar renal cyst decortication can be performed safely with the assistance of the excellent anatomy visualization of the Da Vinci robotic surgical system.