Analysis of 88 nephrectomies in a rural tertiary care center of India

Biswajit Datta; Tapas Moitra; Dhiraj Nundy Chaudhury; Biswajit Halder

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RENAL DATA FROM THE ASIA - AFRICA

Year : 2012 | Volume : 23 | Issue : 2 | Page : 409-413

Analysis of 88 nephrectomies in a rural tertiary care center of India

Biswajit Datta¹, Tapas Moitra¹, Dhiraj Nundy Chaudhury¹, Biswajit Halder²
¹ Department of Urology, North Bengal Medical College, Sushruta Nagar, Darjeeling, India
² Department of Pathology, North Bengal Medical College, Sushruta Nagar, Darjeeling, India

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Date of Web Publication

28-Feb-2012

Abstract

Nephrectomy is not an uncommon surgery in day-to-day practice of urology. Trauma is the most common cause of emergency nephrectomy. On the other hand, elective nephrectomy is done for both benign and malignant diseases of the kidney. This study has been performed to know the different causes of nephrectomy in a rural, tertiary care center of India. In our series, we have studied all the elective nephrectomies done in our hospital during a period of eight years. We have analyzed 88 cases of nephrectomies regarding their age, sex, laterality of disease, and histopathologic report of the nephrectomy specimens. Out of 88 cases, 61 were males and 27 were females. In our series, 62.5% cases of nephrectomies were done for benign causes and 37.5% cases for malignant causes. Among the benign causes, neglected pelviureteric junction obstruction was the leading cause, followed by calculus disease resulting in obstruction. On the other hand, renal cell carcinoma was the most common malignant pathology requiring nephrectomy.

How to cite this article:
Datta B, Moitra T, Chaudhury DN, Halder B. Analysis of 88 nephrectomies in a rural tertiary care center of India. Saudi J Kidney Dis Transpl 2012;23:409-13

How to cite this URL:
Datta B, Moitra T, Chaudhury DN, Halder B. Analysis of 88 nephrectomies in a rural tertiary care center of India. Saudi J Kidney Dis Transpl [serial online] 2012 [cited 2022 Dec 9];23:409-13. Available from: https://www.sjkdt.org/text.asp?2012/23/2/409/93192

Introduction

Like any other human organ, kidney also may be involved by many benign or malignant diseases requiring total removal of the organ. Simple nephrectomy is done to remove the irreversibly damaged, non-functioning kidneys involved by different benign pathological conditions like extensive renal stone disease, obstruction due to impacted calculus in the kidney or ureter, or neglected pelviureteric junction obstruction (PUJO), On the other hand, radical nephrectomy is indicated to treat different malignant conditions of the kidney. In the last few years, there has been a growing interest on nephron-sparing surgery or partial nephrectomy to treat the selected cases of localized renal cell carcinoma (RCC) by open or laparoscopic approach. ^{[1],[2],[3],[4],[5],[6]} In the developed countries, laparoscopic procedures have already replaced the open nephrectomy procedures. ^[7],[8] But in a developing country like India, in many centers, especially those in rural or semi-urban setup, most of the nephrectomies are still now being performed by open surgical techniques. Lack of availability of the instruments, insufficient training during urology residency period, and unavailability of trained urologists in most of the peripheral hospitals are the main responsible factors behind it. In our institute also, till now, laparoscopic urological procedures have not been performed.

Methods

In this retrospective study, we have gone through the medical case records of all the patients undergoing simple or radical nephrectomy between January 2002 and December 2009 to determine the causes of nephrectomies performed among the patients during that period. According to our institutional protocol, elective nephrectomy is done in malignant diseases of the kidney, nonfunctioning kidney diagnosed on intravenous urogram (IVU) or isotope renal scan, uncontrolled hematuria after operation for kidney stone, pyonephrosis, angiomyolipoma, and undiagnosed large renal mass. During the chosen study period, a total of 88 patients underwent elective simple or radical nephrectomy in our department, excluding the cases performed for renal trauma. The clinical data of the patients retrieved included age, sex, clinical features, all pathological and biochemical investigation records, all imaging studies and histopathologic examination reports of the nephrectomy specimens. According to our departmental clinical protocol, every patient was evaluated by detailed history taking and clinical examination. In addition to the clinical examination, all patients were initially imaged by ultrasonography (USG). Then patients were evaluated by intravenous urography (IVU) and contrast-enhanced CT scan (CECT) according to the findings on USG. Radio-nuclide renal scan was performed in three patients below six years of age with USG findings suggestive of PUJO. All the patients showing a mass lesion of the kidney on USG underwent CECT of whole abdomen.

Results

A total of 88 patients underwent nephrectomy during the eight year period. Age of the patients ranged from seven months to 68 years (mean age 21.6 years). Among them, 61 were males and 27 were females (M:F 2.2:1) [Table 1]. Out of 88 nephrectomies, 55 (62.5%) cases were performed for benign conditions of the kidney while 33 (37.5%) cases were performed for malignant conditions [Table 2].

Table 1. Sex and side predilection of the involved patients.

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Table 2. Causes of nephrectomy.

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Among the benign conditions, neglected PUJO leading to loss of renal function (21 cases) was the leading cause for nephrectomy, followed by renal calculus with nonfunctioning kidney (17 cases) [Table 2]. Only three of the above patients with PUJO underwent isotope renal scan, with all of them showing less than 10% relative function of the involved kidney. So, these three patients underwent nephrectomy. In other cases, on IVU, non functioning kidney was diagnosed due to non-excretion of contrast agent by the involved kidney.

One seven month-old female baby presenting with a bimanually palpable kidney lump on right flank and recurrent vomiting underwent CECT of the abdomen as her initial USG of the abdomen showed multiple cystic lesions almost replacing the entire right renal parenchyma. The baby underwent right-sided simple nephrectomy. On histopathologic examination of the specimen, the diagnosis was multicystic dysplastic kidney disease (MCDKD).

On the other hand, RCC was the most common malignant disease (23 cases) followed by Wilms' tumor (7 cases). Four nephrectomies were performed for iatrogenic causes. Three of them underwent nephrolithotomy in peripheral center from where patients were referred to our hospital for persistent uncontrolled hematuria in the postoperative period. One patient underwent nephrolithomy at our hospital for staghorn calculus; the patient developed hematuria on 4 ^th postoperative day and hematuria persisted in spite of all conservative measures. This patient underwent nephrectomy on the 7 ^th postoperative day. In our series, one rare diagnosis was fibromyoblastoma of the right kidney in a 16-year-old girl presenting with a rapidly enlarging huge right renal lump. CECT of whole abdomen showed a hugely enlarged (22 × 10.5 cm) right kidney with mild enhancement. The kidney was free from the surrounding structures. There were no enlarged intra-abdominal lymph nodes. On the other hand, one 20-year-old female presented with a painful left-sided renal lump. On CECT of the whole abdomen, there was a solid appearing mass arising from lower pole of the left kidney with peripheral patchy enhancement and calcification, for which left-sided radical nephrectomy was done. Histopathologic examination of the nephrectomy specimen proved to be a case of primary primitive neuroectodermal tumor (PNET) of the kidney with lymph node metastasis. Among the benign conditions, 37 (67%) kidneys removed were from the left side whereas 18 (33%) kidneys removed were of right side [Table 1]. On the other hand, 24 (72.7%) of the malignant kidneys removed were from left side whereas 9 (27.3%) were from right side [Table 1].

Discussion

There is definitely a geographic variation regarding the indications for nephrectomy. The socioeconomic condition and availability of health care facility is the main factor behind it. In spite of the introduction of minimal invasive techniques in urology, renal preserving surgeries, and development of better medical facilities, the total number of nephrectomies performed in every decade in a large European center does not seem to have changed much over the three decades, from 1960 to 1990. ^[9] But in the same center, with advancement of years, malignant diseases of the kidney had become the more frequent causes for nephrectomy. The reported rates of nephrectomy for malignant conditions from Nigeria ^[10] and Norway ^[11] were 67.3 and 68%, respectively. In a recent series of adult nephrectomies from Nigeria, ^[12] 63% cases were performed for malignant conditions of the kidney. Beisland et al ^[11] have also reported a change in the indications for nephrectomy in Norway during the last few decades, with an increase in the number of nephrectomies being performed for malignant conditions of the kidney. There was also a change in the indications for nephrectomy in a center of Korea ^[12] where 13.75% cases of nephrectomy were done for renal tumor in the period from 1980 to 1987 whereas 57.12% cases of nephrectomy were done for renal tumor in the period from 2000 to 2005. Philips et al ^[14] also reported that in a series of 121 cases, 52 (75.3%) cases of laparoscopic nephrectomy were done for malignant diseases and 69 (24.7%) cases for benign causes.

On the other hand, in a report of 423 consecutive nephrectomies performed in a general hospital of Sudan, ^[15] 70% cases were performed for benign conditions. In a report of 85 adult nephrectomies performed at al Bashir Hospital, Saudi Arabia, ^[16] 77.6% cases of nephrectomies were done for benign conditions. Similarly, in a series of 135 nephrectomies reported from Pakistan, ^[17] 76.6% cases were due to benign causes. In our present series of 88 nephrectomies performed during the study period of eight years, 60.2% cases were performed for benign conditions whereas 39.8% cases were performed for malignant diseases of the kidney. Neglected PUJO was responsible for 25.3% cases, stone related etiology was responsible in 12% cases, and renal tuberculosis was responsible for 10.8% cases of nephrectomies in our series [Table 2].

In most of the reported series, except that from Sudan, malignant diseases of the kidney were the leading causes of nephrectomy. Contrary to this, most of the nephrectomies performed in our series were for benign diseases of the kidney. When most of the study reports showed malignant conditions to be the leading causes of nephrectomy, reports from developping countries like Sudan, Saudi Arabia, and Pakistan showed benign diseases as the leading causes of nephrectomy comparable to our series. Although renal tuberculosis is rare in the western world, incidence of the same is significantly higher in developing countries, including our series.

Two very rare tumors of the kidney were diagnosed on histopathologic examinations of the nephrectomy specimens. One was benign myofibroblastoma and the other one was primary neuroendocrine carcinoma of the kidney. In both of the cases, diagnosis was confirmed after immunohistochemical study.

In this study, there is a much higher rate of nephrectomy performed for benign conditions of the kidney compared to western countries.

Among 88 cases of this series, in 62.5% cases nephrectomy was done for benign conditions, whereas 37.5% cases were for malignant diseases, which is comparable with the series reported from developing countries like Pakistan, Sudan, and Saudi Arabia. Although in developed countries most of the nephrectomies are performed for malignant diseases, benign conditions of the kidney are the leading cause in the developing world. Neglected PUJO and extensive stone disease causing loss of renal function were very common in our center.

References

1.	Kirkali Z. The motion: open partial nephrec-tomy is the standard of care for small resec-table solid renal masses. Eur Urol 2007;51 (2):561-4.
2.	Russo P. Open partial nephrectomy: an essential operation with an expanding role. Curr Opin Urol 2007;17(5):309-15.
3.	Leibovich BC, Blute ML, Cheville JC, et al. Nephron sparing surgery for approximately selected renal cell carcinoma between 4 and 7 cm results in outcome similar to radical nephrectomy. J Urol 2004;171(3):1066-70.
4.	Lau WK, Blute ML, Weaver AL, Torres VE, Zincke H. Matched comparison of radical nephrectomy vs nephron-sparing surgery in patients with unilateral renal cell carcinoma and a normal contralateral kidney. Mayo Clin Proc 2000;75(12):1236-42.32.
5.	Gill IS, Matin SF, Desai MM, et al. Comparative analysis of laparoscopic versus open partial nephrectomy for renal tumors in 200 patients. J Urol 2003;170(1):64-8.
6.	Koenig P, Aron M, Kaouk J, Gill IS. The case for laparoscopic partial nephrectomy. J Endourol 2008;22(9):1917-20.
7.	Sim HG, Yip SK, Ng NY, et al. Laparoscopic nephrectomy: new standard of care? Asian J Surg 2005;28(4):277-81.
8.	Kercher KW, Heniford BT, Mathews BD, et al. Laparoscopic versus open nephrectomy in 210 consecutive patients: outcomes, cost, and changes in practice pattern. Surg Endosc 2003;17:1889-95.
9.	Kubba AK, Hollins GW, Deane RF. Nephrec-tomy: changing indications, 1960-1990. Br J Urol 1994;74:274-8. [PUBMED]
10.	Eke N, Echem RC. Nephrectomy at the University of Port Harcourt Teaching Hospital; A ten year experience. Afr J Med Sci 2003;32:173-7.
11.	Beisland C, Medby PC, Sander S, Beisland HO. Nephrectomy-indications, complications and post-operative mortality in 646 consecutive patients. Eur Urol 2000;37:58-64. [PUBMED]
12.	Badmus TA, Salako AA, Sanusi AA, Arogunta A, Oseni GO, Yusuf BM. Adult nephrectomy: Our experience at Ile-lfe. Niger J Clin Pract 2008;11(2):121-6.
13.	Kim K, Cho C. Analysis of the causes of nephrectomy in 1980-2005. Urology 2007;70 (3):34.
14.	Phillips J, Catto JW, Lavin V, et al. The laparoscopic nephrectomy learning curve; a single centre's development of a de novo practice. Postgrad Med J 2005;81:599-603. [PUBMED] [FULLTEXT]
15.	Ghalayini IF. Pathological spectrum of neph-rectomies in a general hospital. Asian J Surg 2002;25:163-9. [PUBMED] [FULLTEXT]
16.	Malik EF, Memon SR, Ibrahim AL, Gizawi AA, Ghali AM. Nephrectomy in adults: Asir Hospital experience. Saudi J Kidney Dis Transplant 1997;8(4):423-7.
17.	Rafique M. Nephrectomy: Indications, complications and mortality in 154 consecutive patients. J Pak Med Assoc 2007;57(6):308-1.