1699Vol. 11 | No. 03 | May - June 2014 |U R O LO G Y J O U R N A L Transumbilical Laparoendoscopic Single- Site Decortication of Peripelvic Renal Cyst: A Case Report Yao He, Zhi Chen, Xiao-Long Fang, Yan-Cheng Luo, Peng-Yang Dai, Miao-Long Lu, Xiang Chen Corresponding Author: Xiang Chen, MD Department of Urology, Xiangya Hospital, Central South University, No. 87 Xiangya Road Changsha 410008,China. Tel: +86 013874808998 E-mail: cxiang1007@126.com Received March 2013 Accepted February 2014 Department of Urology, Xiangya Hospital, Central South University, Changsha 410008, China. CASE REPORT Keywords: kidney; cyst; laparoscopy; methods; umbilicus; kidney diseases; cystic. INTRODUCTION Recently, laparoendoscopic single-site surgery (LESS) has been introduced and rep-resents the latest evolution in minimally invasive therapeutic techniques.(1) Several studies have demonstrated that it is a safe and effective therapy for many urologi- cal diseases.(2-4) However, LESS decortication for peripelvic cyst is still an infrequently de- scribed technique. In this report, we describe a case of peripelvic cyst that was successfully managed by transumbilical LESS decortication. CASE REPORT A 31-year-old female presented with recurrent left flank pain. Abdominal ultrasonography detected a left renal cyst. A computed tomography (CT) scan, with delayed views, identified a left peripelvic cyst measuring 7.5×7.0×6.8 cm, which was not communicating with the collecting system (Figure 1A). Retrograde pyelography (RP) also demonstrated the cyst was not in communication with the collecting system. She was managed by transumbilical LESS decortication. Informed consent was obtained before the surgery. Surgical Technique After induction of general anesthesia, a 5 French (F) open-ended ureteral catheter was placed by cystoscope for instillation of methylene blue. Subsequently, the patient was placed in a 45° lateral decubitus position. A TriPort Access System was introduced through a 2 cm semi- 1700 | circular periumbilical incision (Figure 2A). Harmonic scal- pel was used for incising the line of Toldt and the descend- ing colon was mobilized and reflected medially to expose the kidney. After carefully clearing away the perinephric fat to expose the renal pelvis, the renal vessels were isolated and the peripelvic cyst was exposed. The cyst was incised, and fluid was carefully aspirated for cytologic examination. Most of the cyst wall was excised and sent for histopatho- logical examination (Figure 2B). Fulguration was not per- formed to reduce the chance of fistula formation with the collecting system and major renal vessels. A drain was not placed. The operative time was 122 min and the estimated blood loss was 20 mL. No intraoperative or postoperative com- plications occurred. The postoperative analgesia was not needed. The patient resumed oral food intake on day 2 and was discharged on day 3, postoperatively. All cytology and cyst wall pathologic findings were negative for malignancy. At 3-month follow-up, a CT scan demonstrated no cyst recurrence (Figure 1B). The patient was very satisfied be- cause she remained symptom free and the umbilical scar was barely visible (Figure 2C). DISCUSSION Currently, laparoscopic decortication has substituted for open technique and is admitted as a standard treatment of symptomatic peripelvic cysts. A number of reports have also been published, documenting successful results of laparoscopic decortications using either a transperitoneal or retroperitoneal route.(5-9) Nevertheless, with increasing ex- perience in the laparoscopic environment, surgeons are still working on ways to further improve cosmetic outcomes and minimize surgical morbidity. This trend has led to the development of new techniques such as mini-laparoscopic Case Report Figure 1. Preoperative and postoperative computed tomography scans; (A) preoperative computed tomography scan demonstrates a left peripelvic renal cyst, (B) postoperative computed tomography scan at the 3-month follow-up demonstrated no cyst recurrence. Figure 2. (A) TriPort Access System was introduced through a 2 cm semicircular periumbilical incision, (B) neither additional cysts nor any areas suspicious for carcinoma were detected in the interior of the cavity, (C) the umbilical scar is barely visible at postoperative day 30. 1701Vol. 11 | No. 03 | May - June 2014 |U R O LO G Y J O U R N A L LESS Decortication of Peripelvic Cyst | He et al surgery and LESS. However despite widespread reports of LESS for simple renal cyst decortication, LESS decortica- tion for peripelvic cyst is still an infrequently described technique. Compared with LESS decortication of simple renal cyst, LESS peripelvic cyst decortication faces more technical challenges due to its complexity and multilobu- lated feature of cyst and the intimate association to the renal hilar structures. Thus, the surgeon should not only be famil- iar with the procedure of LESS but also have experience in LESS urinary tract reconstruction in response to the inad- vertent collecting system injury. We had completed over 200 cases of LESS procedures including over 50 cases of LESS urinary tract reconstruc- tion such as dismembered pyeloplasty, ureterolithotomy and ureteroureterostomy before beginning LESS peripelvic cyst decortication. Moreover, using a combination of the high-quality CT imaging and retrograde pyelography pre- operatively is essential to determine the possible number and configuration of cysts and to rule out collecting system communications. It is also necessary to inject methylene blue through an open-ended retrograde ureteral catheter intraoperatively that can help surgeons distinguish the col- lecting system from cysts, and make an early diagnosis and timely treatment of unsuspected collecting system injury. CONCLUSION In conclusion, the transumbilical LESS decortication is technically feasible, and can be considered as potential al- ternative for conventional laparoscopic surgery. ACKNOWLEDGMENTS Yao He and Zhi Chen contributed equally to this work. CONFLICT OF INTEREST None declared. REFERENCES 1. Kaouk JH, Autorino R, Kim FJ, et al. Laparoendoscopic single-site surgery in urology: worldwide multi-institutional analysis of 1076 cases. Eur Urol. 2011;60:998-1005. 2. Cindolo L, Gidaro S, Tamburro FR, Schips L. Laparo-endoscopic sin- gle-site left transperitoneal adrenalectomy. Eur Urol. 2010;57:911-4. 3. Fadahunsi AT, Sanford T, Linehan WM, Pinto PA, Bratslavsky G. Feasi- bility and outcomes of partial nephrectomy for resection of at least 20 tumors in a single renal unit. J Urol. 2011;185:49-53. 4. Dasgupta P. Laparoendoscopic single-site pyeloplasty: a com- parison with the standard laparoscopic technique. BJU Int. 2011;107:816. 5. 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