Long-term follow-up of a juvenile simple renal cyst in a dog treated by laparoscopic deroofing, fulguration, and omentalization

Bastien Dekerle Department of Small Animal Surgery and Department of Internal Medicine, Centre Hospitalier Universitaire Vétérinaire d’Alfort (CHUVA), Université Paris Est, École Nationale Vétérinaire d’Alfort, Maisons-Alfort Cedex, France

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Virginie Fabres Department of Small Animal Surgery and Department of Internal Medicine, Centre Hospitalier Universitaire Vétérinaire d’Alfort (CHUVA), Université Paris Est, École Nationale Vétérinaire d’Alfort, Maisons-Alfort Cedex, France

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Ghita Benchekroun Department of Small Animal Surgery and Department of Internal Medicine, Centre Hospitalier Universitaire Vétérinaire d’Alfort (CHUVA), Université Paris Est, École Nationale Vétérinaire d’Alfort, Maisons-Alfort Cedex, France

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Mathieu Manassero Department of Small Animal Surgery and Department of Internal Medicine, Centre Hospitalier Universitaire Vétérinaire d’Alfort (CHUVA), Université Paris Est, École Nationale Vétérinaire d’Alfort, Maisons-Alfort Cedex, France

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Abstract

CASE DESCRIPTION

A 10-month-old male crossbred dog presented with a 4-week history of polyuria and polydipsia and a 6-month history of vomiting.

CLINICAL FINDINGS

Clinical examination revealed abdominal pain and right-sided nephromegaly. Biochemistry was within normal limits. Diagnostic imaging showed a well-defined, unilateral renal mass containing anechoic fluid consistent with a simple renal cyst (SRC).

TREATMENT AND OUTCOME

The cyst was drained under ultrasonographic guidance but recurred 3 months later, concomitant with recurrence of the previously reported clinical signs. The cyst was then deroofed, fulgurated, and omentalized under laparoscopy by use of a 3-port technique. The resected cystic wall was histopathologically consistent with an SRC, presumptively congenital. The dog showed a good recovery with resolution of clinical signs. Renal function was normal at last follow-up, conducted 2 years postoperatively, without evidence of recurrent disease.

CLINICAL RELEVANCE

To our knowledge, this was the first report of a symptomatic juvenile SRC of presumptively congenital origin in a dog treated successfully by laparoscopic deroofing, fulguration, and omentalization. The polyuria, polydipsia, chronic vomiting, and abdominal pain may all have been related to space-occupying effects of the cyst, as these symptoms resolved post-treatment. Results of long-term follow-up advocate for this durable cure of SRC by use of laparoscopic procedures, especially when compared to simple drainage of the cyst, as the latter initially failed in the present case.

Abstract

CASE DESCRIPTION

A 10-month-old male crossbred dog presented with a 4-week history of polyuria and polydipsia and a 6-month history of vomiting.

CLINICAL FINDINGS

Clinical examination revealed abdominal pain and right-sided nephromegaly. Biochemistry was within normal limits. Diagnostic imaging showed a well-defined, unilateral renal mass containing anechoic fluid consistent with a simple renal cyst (SRC).

TREATMENT AND OUTCOME

The cyst was drained under ultrasonographic guidance but recurred 3 months later, concomitant with recurrence of the previously reported clinical signs. The cyst was then deroofed, fulgurated, and omentalized under laparoscopy by use of a 3-port technique. The resected cystic wall was histopathologically consistent with an SRC, presumptively congenital. The dog showed a good recovery with resolution of clinical signs. Renal function was normal at last follow-up, conducted 2 years postoperatively, without evidence of recurrent disease.

CLINICAL RELEVANCE

To our knowledge, this was the first report of a symptomatic juvenile SRC of presumptively congenital origin in a dog treated successfully by laparoscopic deroofing, fulguration, and omentalization. The polyuria, polydipsia, chronic vomiting, and abdominal pain may all have been related to space-occupying effects of the cyst, as these symptoms resolved post-treatment. Results of long-term follow-up advocate for this durable cure of SRC by use of laparoscopic procedures, especially when compared to simple drainage of the cyst, as the latter initially failed in the present case.

Introduction

A 10-month-old 23-kg sexually intact male crossbred dog with a body condition score of 4/9 was presented with a 4-week history of polyuria polydipsia (PUPD) and a 6-month history of abdominal discomfort and chronic vomiting. Abdominal palpation revealed right-sided deformation under the last thoracic ribs suggestive of right-sided nephromegaly and associated pain.

Abdominal ultrasonography revealed the presence of a large (58 X 54 mm), ovoid, well-delineated, thin-walled anechoic mass in the cranial third of the right kidney consistent with a cyst (Figure 1). The left kidney was within normal limits. Cytologic examination of the fluid drained from the cyst under ultrasonographic guidance revealed low cellularity with a majority of RBCs and some macrophages. Bacteriologic culture was negative. Cystic fluid creatinine-to-serum creatinine ratio (0.54; reference range, < 2) excluded a communicating urinary cyst.

Figure 1
Figure 1

Abdominal ultrasonography of a 10-month-old, sexually intact, male crossbred dog with a 4-week history of polyuria and polydipsia and a 6-month history of vomiting. Notice the well-defined, large mass (58 X 54 mm) containing anechoic fluid and distal acoustic enhancement. Note the thin wall of the lesion.

Citation: Journal of the American Veterinary Medical Association 260, 11; 10.2460/javma.21.06.0272

Blood biochemistry revealed a mild increase in symmetric dimethylarginine (SDMA) concentration without associated azotemia (Table 1). Urinalysis of a sample collected via cystocentesis revealed specific gravity of 1.020, urine protein-to-creatinine ratio of 0.11 (reference range, < 0.2), and no pyuria or bacteriuria on sediment examination. Systolic blood pressure was 120 mm Hg as measured by Doppler technique according to American College of Veterinary Internal Medicine guidelines.1 On the basis of these findings, the diagnosis of a simple renal cyst (SRC) was made.

Table 1

Evolution of blood symmetric dimethylarginine (SDMA) and creatinine concentrations, urine specific gravity (USG), and bilateral kidney size during follow-up of the dog of the present report.

Day SDMA (μg/dL) [RI] Creatinine (mg/dL) [RI] USG Right kidney size (mm) Cyst size (mm) Left kidney size (mm)
0 (presentation) 17 [0–14] 1.4 [0.5–1.6] 1.020 NE 60 66
112 14 [0–14] 1.3 [0.5–1.6] 1.038 NE 43 60
143 (surgery) 1.1 [0.5–1.6] 62 NA 59
174 60 NA 65
727 5 [0–14] 1.4 [0.5–1.6] 1.032 61 NA 61
944 10 [0–14] 1.2 [0.5–1.6] 1.045 60 NA 70

NA = Not applicable. NE = Not evaluated. RI = Reference interval.

Complete drainage of the cyst was performed under ultrasonographic guidance, resulting in complete resolution of clinical signs. However, relapse of clinical signs was reported 3 months postdrainage and abdominal ultrasonography revealed recurrence of the cyst (43 X 38 mm). Surgical treatment was advised and subsequently performed by laparoscopy.

The dog was positioned in left lateral recumbency. The 5-mm primary port was placed caudally and laterally to the umbilicus by use of a modified Hasson technique. Pneumoperitoneum (10 mm Hg) was then induced by carbon dioxide insufflation through the cannula, and a 5-mm zero-degree telescope was inserted. Two additional 5-mm ports were then placed under laparoscopic control, caudal to the last rib at the level of the chondrocostal junction for the cranial port and in the paralumbar fossa for the caudal port.

Exploratory laparoscopy confirmed the SRC in the cranial third of the right kidney (Figure 2). The entirety of the cystic fluid was percutaneously aspirated (35 mL) under endoscopic guidance with a 22-gauge needle after blunt dissection of the peritoneum over the kidney. The SRC was opened with laparoscopic scissors and circumferentially resected as close to the renal parenchyma as possible with a 5-mm vessel-sealing device (LigaSure Atlas; Covidien; Figure 3). The remaining cystic wall on the renal parenchyma was then fulgurated via monopolar electrosurgery. During fulguration, small amounts of clear fluid were observed, suggestive of pelvicalyceal tears and associated urine leakage. The kidney was subsequently closed to prevent further leakage with 3 simple interrupted horizontal mattress sutures (3-0 polydioxanone) placed caudocranially to the remaining cyst margins (Figure 4). A renal biopsy was performed at the caudal pole of the right kidney by use of a 14-gauge needle and an automatic device. Nephropexy of the craniolateral part of the kidney to the transversalis abdominal muscle was performed to prevent torsion of the kidney after retroperitoneum opening (3-0 polydioxanone), and the kidney was subsequently omentalized.

Figure 2
Figure 2
Figure 2
Figure 2

Laparoscopic views of the drainage and exposition of the simple renal cyst (SRC) of the dog in Figure 1. A—Exploratory laparoscopy showing the SRC in the cranial third of the right kidney (asterisk). B—Blunt dissection of the peritoneum overlying the kidney. C—Percutaneous drainage of the cyst by use of a 22-gauge needle. The needle has been inserted through the abdominal wall under laparoscopic observation. Cd = Caudal. Cr = Cranial.

Citation: Journal of the American Veterinary Medical Association 260, 11; 10.2460/javma.21.06.0272

Figure 3
Figure 3
Figure 3
Figure 3

Laparoscopic views of the deroofing and fulguration of the SRC of the dog in Figure 1. A—Deroofing of the cyst along the renal cortical margins using laparoscopic fenestrated bowel grasper forceps and a vessel-sealing device. B—Aspect of the internal wall of the cyst at the completion of deroofing. C—Fulguration of the cyst using a monopolar electrosurgery device. See Figure 2 for key.

Citation: Journal of the American Veterinary Medical Association 260, 11; 10.2460/javma.21.06.0272

Figure 4
Figure 4
Figure 4
Figure 4

Laparoscopic views of the closure and omentalization of the SRC of the dog in Figure 1. A—Simple interrupted horizontal mattress suture renorrhaphy was performed with 3-0 polydioxanone to limit urine leakage following fulguration. B—Ventral view of the kidney after final closure of the cyst margins. C—Omentalization of the kidney with 3-0 polydioxanone sutures. See Figure 2 for key.

Citation: Journal of the American Veterinary Medical Association 260, 11; 10.2460/javma.21.06.0272

The port sites were closed in routine fashion. The dog’s recovery was uneventful, and it was discharged 2 days postsurgery.

On histopathological examination, the cyst wall was composed of a single layer of cubical to columnar cells surrounded by a dense fibrous capsule and atrophied tubules and glomeruli; renal tissue from kidney biopsy was otherwise within normal limits without any sign of fibrosis or underlying renal disease, suggestive of benign congenital renal cyst (RC).

The dog was reexamined 1-month postsurgery and every 6 months after; clinical examinations were unremarkable. The owners reported complete resolution of all symptoms, including PUPD.

At the final follow-up, conducted 2 years postsurgery, ultrasonographic examination revealed no recurrence of the cyst, while blood SDMA and creatinine concentrations and urine specific gravity values were within reference intervals, and the size of both kidneys, assessed by ultrasonography, remained stable (Table 1).

Discussion

Renal cysts are fluid-filled, epithelium-lined cavities that can be single or multiple in occurrence, congenital or acquired in origin, and simple or complicated in nature (depending on the contents of cells, bacteria, or fungi).2,3 Differential diagnosis includes communicating RC, calyceal diverticulum, and neoplasm.4,5 Simple renal cysts are common in human adult patients, although sparsely reported in dogs. In humans, the overwhelming majority of SRC are diagnosed incidentally and require no further evaluation or treatment in the absence of clinical signs.2 It should be noted, however, that asymptomatic untreated cysts can increase in both size and number over time, especially in younger patients, potentially leading to the development of chronic interstitial lesion of the kidney, pain, infection, glomerular hypertension, hemorrhage, collecting system obstructions, or neoplastic transformation.2,58 The physiopathology of SRC remains unclear, both in human and veterinary medicine. It has been hypothesized that the PUPD associated with RC is a consequence of stimulation of the renin-angiotensin-aldosterone system secondary to renal parenchyma compression and ischemia induced by the cyst; however, this is unlikely in the present case considering the lack of systemic blood hypertension.9 Impaired renal function has previously been described in dogs and cats with polycystic kidney disease or SRC localized near the pelvis; however, it remains undetermined whether this altered renal function is a consequence of the cysts or an associated disease, as acquired cysts have also been described secondary to chronic nephropathies.3,7,10,11 In dogs, polycystic diseases have been reported in Bull Terriers; however, the onset of associated clinical signs is generally late and diagnosis is delayed.12 In the present case, the presence of clinical signs, size of the cyst, and young age of the dog advocated for a therapeutic approach. Analysis of both the cystic fluid and the cyst wall, along with the lack of histopathological anomalies in the surrounding renal parenchyma, favor a congenital origin of disease in this dog. The observed clinical improvement advocated for the SRC being implicated in the symptoms described at presentation. Concerning parameters of renal function, creatinine was near the upper limit of the reference range while SDMA was increased; however, both these parameters are known to possess relatively high interindividual variability and increases in SDMA have been described in growing dogs.13 Moreover, no dehydration or pelvic dilation were detected at diagnosis that would explain increases in these parameters from a prerenal or postrenal cause.

A variety of therapeutic interventions have been described for benign symptomatic cystic lesions of the kidney, both in human and veterinary medicine. These interventions include percutaneous aspiration, with or without associated sclerotherapy, open cyst decortication, and laparoscopic deroofing.2,8,14 Percutaneous drainage was performed as first-line therapy in the present case; however, short-term recurrence occurred, consistent with reports in human medicine.6,14 Sclerotherapy, commonly performed in humans, has previously been described in dogs with acquired RC and demonstrated good short-term outcomes3; however, in humans, recurrence has been seen in up to 45% of cases and severe bleeding is a potential complication.6,1416

Laparoscopic treatment is currently considered as the surgical treatment of choice for RC in human medicine when percutaneous drainage and sclerotherapy have failed. This technique combines the advantages of a minimally invasive approach with excellent visualization and magnification of the inner aspect of the cyst, allowing excision of the cyst wall and ablation of its epithelial surface.8,15,17 Furthermore, recent data have shown that laparoscopic deroofing is superior to sclerotherapy in terms of success rates and recurrence rates, with no differences witnessed regarding potential complications.8 In veterinary medicine, there is a paucity of literature describing surgical management of SRC in dogs; recently, laparoscopic surgical resection and omentalization has been described in 2 dogs, one with benign acquired RC and the other with cystic renal adenoma.4,5 In the present case, fulguration of the remaining cyst wall in close contact to the renal parenchyma was performed after cyst resection, to destroy any secretory activity of the residual epithelial cells and prevent long-term recurrence. Fulguration has been suggested to decrease recurrence rates in human patients; the procedure can either be performed by argon beam coagulators or monopolar electrosurgery, as was described in the present case.15,17,18 The use of fulguration, however, is thought to increase the risk of bleeding and iatrogenic tears to the collecting system, as was assumed to occur in the present case.6,14 Subsequent treatment of iatrogenic tears to the collecting system has been described via hemostatic agents, fibrin sealants, autologous fat grafts, drain placement, and suturing.19 In the present case, considering the outcome, transverse closure of the kidney following cyst resection and subsequent omentalization was found to be adequate in preventing further urinary leakage.

The laparoscopic management of symptomatic congenital SRC, reported here in a dog, was considered successful, resulting in complete resolution of clinical signs and no cyst recurrence over a 2-year follow-up, suggesting that laparoscopic deroofing, fulguration, and omentalization is a minimally invasive kidney-sparing technique associated with effective and durable treatment. Further cases are, however, needed to draw definitive conclusions and confirm the potential advantages of cyst fulguration.

Acknowledgments

No third-party funding or support was received in connection with this study or the writing or publication of the manuscript. The authors declare that there were no conflicts of interest.

This case report has been selected to be displayed as a virtual poster during the 30th European College of Veterinary Surgeons Annual Scientific Meeting.

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