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Saudi Journal of Kidney Diseases and Transplantation
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RENAL DATA FROM ASIA - AFRICA  
Year : 2015  |  Volume : 26  |  Issue : 3  |  Page : 638-642
Nephrectomy in adults: Experience at the Korle Bu Teaching Hospital, Accra, Ghana


1 Department of Surgery/Urology, University of Ghana Medical School, Accra, Ghana
2 Department of Pathology, University of Ghana Medical School, Accra, Ghana

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Date of Web Publication20-May-2015
 

   Abstract 

The objective of this study was to analyze nephrectomies performed in adults over a 12-year period at the Korle Bu Teaching Hospital, Accra and to compare our findings with reports from other institutions. In this retrospective study, medical records of 97 consecutive adult patients who underwent nephrectomy from January 2000 to December 2011 were reviewed. The parameters extracted included the patients' age, gender, indication for nephrectomy and the side of nephrectomy. Also considered were the histology of the nephrectomy specimen and the peri-operative mortality. The data were analyzed using the Statistical Package for Social Sciences for Windows (Version 19.0). Of the 97 nephrectomies performed, 62 were performed for suspected malignant renal tumors and 35 were performed for clinically benign renal conditions. Malignancy was confirmed in 85.5% (53/62) of the suspected cases. The mean age of this group was 52.2 ± 15.5 years and the male to female ratio was 1:0.9. Thirty-two tumors (60.4%) were in the right kidney and 21 (39.6%) tumors were in the left kidney; the mean tumor size was 16.8 ± 4.0 cm. The predominant presenting complaints included flank pain (67.9%), flank mass (50.9%) and hematuria (24.5%). In one case (1.9%), the renal mass was found incidentally. Among patients who had benign disease, non-functioning kidney due to renal cystic disease was the most common lesion (11/44; 25.0%). A peri-operative mortality rate of 3.1% was recorded. Our study suggests that malignant renal tumors constitute the main indication for nephrectomy in our institution. Non-functioning kidney due to renal cystic disease was the most common benign renal indication for nephrectomy.

How to cite this article:
Kyei MY, Klufio GO, Mensah JE, Gyasi RK, Gepi-Attee S, Ampadu K. Nephrectomy in adults: Experience at the Korle Bu Teaching Hospital, Accra, Ghana. Saudi J Kidney Dis Transpl 2015;26:638-42

How to cite this URL:
Kyei MY, Klufio GO, Mensah JE, Gyasi RK, Gepi-Attee S, Ampadu K. Nephrectomy in adults: Experience at the Korle Bu Teaching Hospital, Accra, Ghana. Saudi J Kidney Dis Transpl [serial online] 2015 [cited 2021 Jan 20];26:638-42. Available from: https://www.sjkdt.org/text.asp?2015/26/3/638/157438

   Introduction Top


Nephrectomy, which involves the removal of a kidney, is carried out for both benign and malignant lesions. It has been noted that it offers long-term benefits in cancer-specific survival in localized renal tumors [1] and for lifethreatening benign renal conditions. In Ghana, a study by Klufio et al indicated that renal tumors constituted 10.4% of genito-urinary cancers seen at the Korle Bu Teaching Hospital. [2] The indications for nephrectomy have been noted to vary among institutions and regions. [3] In the case of renal tumors, size of the tumor at diagnosis has been shown to lead to steadily deteriorating survival, especially when the tumor size is above 4 cm. [4] Thus, knowledge of the average size of renal tumors at diagnosis could be helpful in understanding institutional outcomes following the treatment of affected patients. Even though laparoscopic nephrectomy has been established as a minimally invasive operative procedure, [5] open nephrectomy remains the surgical approach for renal surgery at our institution on account of lack of logistics and expertise.

The objective of this study was to analyze nephrectomies performed in adults over a 12year period at the Korle Bu Teaching Hospital, Accra and to compare our findings with reports from other institutions.


   Subjects and Methods Top


The records of consecutive adult patients who underwent nephrectomy at the Department of Surgery/Urology at the Korle Bu Teaching Hospital in Accra from January 2000 to December 2011 were reviewed. The parameters extracted included patients' age, gender and indication for and laterality of the nephrectomy. Also considered were the histology of the nephrectomy specimen and the peri-operative mortality. The investigations used in the evaluation of the renal pathologies included abdominal ultrasound, intravenous urography, abdomino - pelvic computerized tomography (CT) scan and radioisotope renal scan to assess differential renal function in some of the benign conditions. A radioisotope renal scan with a differential renal function of less than 10% was considered suggestive of a non-/poorly functioning kidney. Patients with benign renal lesions underwent simple nephrectomy while those with suspected malignant renal tumors and transitional cell carcinoma of the renal pelvis underwent radical nephrectomy and nephroureterectomy, respectively.

The data were analyzed using the Statistical Package for the Social Sciences (SPSS) for Windows (Version 19.0).


   Results Top


Ninety-seven nephrectomies were carried out over the 12-year study period; 62 of them were for suspected malignant renal tumors and 35 for benign renal conditions. Five cases were excluded from the series as they were found to have inoperable tumors with extension beyond the fascia gerota and associated liver metastasis.

The mean age of the 97 eligible patients was 48.9 ± 16.1 years (range 19 - 75 years). Forty-nine (50.5%) were male and 48 (49.5%) were female, with a male to female ratio of 1:1. Of the 62 nephrectomies performed for suspected malignant renal tumors, 53 (85.5%) were subsequently proven histologically to be malignant while nine cases (14.5%) were found to be benign [Table 1].
Table 1: Histology of suspected malignant renal tumors after nephrectomy.

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Among the 53 patients who underwent radical nephrectomy or nephro-ureterectomy for malignant renal tumors confirmed histologically, the mean age was 52.2 ± 15.5 years (range 19 - 74 years), with a male to female ratio of 1:0.9. Among patients with benign renal conditions, the mean age was 44.8 ± 15.9 years (range 21 - 75 years), with a male to female ratio of 1:1.

Patients who had malignant renal tumors (n = 53) presented clinically with flank pain in 67.9%, flank mass in 50.9% and hematuria in 24.5% of the patients. In one case, the renal mass was found incidentally (1.9%). Thirty-two tumors (60.4%) were present on the right side and 21 (39.6%) tumors were present on the left side. The mean tumor size was 16.8 ± 4.0 cm (range 10 - 28 cm). Six of the patients (11.3%) had associated lymph node involvement. One case of squamous carcinoma was associated with stones in the renal pelvis, while the case with granulosa cell tumor was considered as metastasis from a right ovarian tumor.

Forty-four patients (45.4%) underwent nephrectomy for benign diseases. Thirty-five of them were diagnosed pre-operatively while the remaining nine were suspected to be malignant initially but subsequently found to be benign on histological examination of the nephrectomy specimen [Table 2].
Table 2: Benign renal diseases leading to nephrectomy.

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Three peri-operative mortalities were recorded: Two were caused by hemorrhage and one was due to pulmonary embolism confirmed at autopsy. The overall peri-operative mortality rate was 3.1%.


   Discussion Top


Malignant renal lesions constituted the predominant indication for nephrectomy in our institution (54.6%). This is similar to a study from Nigeria where radical nephrectomy for malignant renal tumors constituted 53.3% in one study [6] and 67% in another study. [7] However, in reports from Pakistan and rural India, nephrectomy for malignant renal disease constituted 23% and 37.5%, respectively, [3],[8] thus supporting an observed regional variation in the indications for nephrectomy.

The mean age of the patients with malignant renal lesions in this study was 52.2 years compared with 47.5 years in a Nigerian study. [9] It however conforms to studies from other parts of the world. [3],[10] This mean age of 52.2 years was significantly higher than the mean age of the patients who had nephrectomy for benign renal conditions, which was 44.8 years in this series (P <0.05).

There was a slight male preponderance among patients who underwent nephrectomy for malignant renal tumors (M:F of 1:0.9); this is in accordance with reports from other West African countries and internationally. [9],[11],[12] Most of the malignant renal tumors were on the right side (60.4%). This is in contrast to reports from West Africa and the rest of the world, where the tumors were more common on the left side (54 - 55% vs. 44 - 46%). [9],[12] This may be due to a selection bias or small sample size.

Nearly all the patients were symptomatic at presentation. The presenting symptoms in decreasing order of frequency were flank pains, flank mass and hematuria. This order of frequency in presenting symptoms was also observed in a study from Nigeria. [9] Despite the increasing use of ultrasound and other crosssectional imaging studies in Ghana, only one case of renal mass was discovered incidentally in this series.

Most of the patients presented late, with a mean tumor size of 16.8 cm. A study by Latif et al [12] also showed a fairly large mean tumor size of 8.6 cm. This suggests late presentation when compared with the relatively small tumor sizes of predominantly incidental renal tumors reported from the western industrialized countries. [4],[10],[13],[17]

Malignant renal tumors remain an uncommon urological tumor in Ghana as an average of four cases per year is seen in our center, a major referral center. This is in accordance to an earlier study in which renal tumors constituted 10.4% of urological tumors seen at the Korle Bu Teaching Hospital. [2]

Following radical nephrectomy/nephro-ureterectomy, 85.5% of the cases suspected to have malignant renal tumors before surgery were confirmed positive by histology, with renal cell carcinoma being the predominant histological type (83%). Corresponding figures of 94% and 87.2%, respectively, were reported by Latif et al. [12] It is noteworthy that not all patients with suspected malignant lesions were found histologically to be malignant. This has also been observed in other studies. [12] Thus, histological assessment of all nephrectomy specimens is mandatory. The granulosa cell tumor observed on histology was considered to be metastasis from a right ovarian tumor.

The most common benign renal disease leading to nephrectomy was non-/poorly functioning kidneys with associated pain due to renal cystic disease (11/44; 25.0%). This differs from a study by Rafique [3] where non-/poorly functioning kidneys due to stone disease constituted the majority (53.3%) of the cases of simple nephrectomy. Stone-related conditions constituted 15.9% in this study. Simple nephrectomy can be largely reduced with early diagnosis and treatment of such underlying conditions.

No case of renal tuberculosis as an indication for simple nephrectomy was recorded in this series compared with nine cases (10.2%) reported by Data et al from rural India. [8] Renal trauma was an uncommon indication for nephrectomy in this series seen in two of 97 cases (2.1%). This supports similar findings in studies from Nigeria. [6],[7]

A recorded post-operative mortality rate of 3.1% compares with 1.29% in the report by Muhammad Rafique [3] and 3.7% by Badmus et al. [6]


   Conclusion Top


Suspected malignant renal tumors are the predominant indication for nephrectomy in our institution. Histological examination of the nephrectomy specimen confirmed the diagnosis in 85.5% of the cases, with most of the patients presenting late, with a mean tumor size of 16.8 cm. Renal cell carcinoma was the most common tumor type. The most common benign renal disease leading to nephrectomy was nonfunctioning kidneys due to renal cystic disease (25%). A peri-operative mortality rate of 3.1% was recorded.

Conflict of interest: None

 
   References Top

1.
Weight CJ, Larson BT, Fergany AF, et al. Nephrectomy Induced Chronic Renal Insufficiency is Associated with Increased Risk of Cardiovascular Death and Death From Any Cause in Patients With Localized cT1b Renal Masses. J Urol 2010;183:1317-23.  Back to cited text no. 1
    
2.
Klufio GO. A review of genitourinary cancers at the Korle-Bu teaching hospital Accra, Ghana. West Afr J Med 2004;23:131-4.  Back to cited text no. 2
    
3.
Rafique M. Nephrectomy: Indications, complications and mortality in 154 consecutive patients. J Pak Med Assoc 2007;57:308-11.  Back to cited text no. 3
    
4.
Nguyen MM, Gill IS, Ellison LM. The Evolving Presentation of Renal Carcinoma in the United States: Trends From the Surveillance, Epidemiology, and End Results Program. J Urol 2006;176:2397-400.  Back to cited text no. 4
    
5.
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.  Back to cited text no. 5
    
6.
Badmus TA, Salako AA, Sanusi AA, Arogundade FA, Oseni GO, Yusuf BM. Adult nephrectomy: Our experience at Ile-Ife. Niger J Clin Pract 2008;11:121-6.  Back to cited text no. 6
[PUBMED]    
7.
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.  Back to cited text no. 7
    
8.
Data 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.  Back to cited text no. 8
    
9.
Badmus TA, Salako AB, Arogundade FA, et al. Malignant Renal Tumors in Adults: A Ten-Year Review in a Nigerian Hospital. Saudi J Kidney Dis Transpl 2008;19:120-6.  Back to cited text no. 9
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Kassouf W, Aprikian AG, Laplante M, Tanguay S. Natural history of renal masses followed expectantly. J Urol 2004;171:111-3.  Back to cited text no. 10
    
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Woldrich JM, Mallin K, Ritchey J, Carroll PR, Kane CJ. Sex differences in renal cell cancer presentation and survival: An analysis of the National Cancer Database, 1993-2004. J Urol 2008;179:1709-13.  Back to cited text no. 11
    
12.
Latif F, Mubarak M, Kazi JI. Histopathological characteristics of adult renal tumors: A preliminary report. J Pak Med Assoc 2011;61: 224-8.  Back to cited text no. 12
    
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Pantuck AJ, Zisman A, Belldegrun AS. The changing natural history of renal cell carcinoma. J Urol 2001;166:1611-23.  Back to cited text no. 13
    
14.
Rendon RA, Stanietzky N, Panzarella T, et al. The natural history of small renal masses. J Urol 2000;164:1143-7.  Back to cited text no. 14
    
15.
Thompson IM, Peek M. Improvement in survival of patients with renal cell carcinoma: The role of the serendipitously detected tumor. J Urol 1988;140:487-90.  Back to cited text no. 15
    
16.
Ueda T, Mihara Y. Incidental detection of renal carcinoma during radiological imaging. Br J Urol 1987;59:513-5.  Back to cited text no. 16
    
17.
Bosniak MA. Observation of small incidentally detected renal masses. Semin Urol Oncol 1995;13:267-72.  Back to cited text no. 17
    

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Correspondence Address:
Dr. Mathew Y Kyei
Department of Surgery and Urology, University of Ghana Medical School, P.O. Box 4236, Accra
Ghana
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DOI: 10.4103/1319-2442.157438

PMID: 26022047

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