BERKELEY, CA (UroToday.com) - Chronic pain occurs in the majority of patients with autosomal dominant polycystic kidney disease (ADPKD) and can be refractory to conservative, medical, and other non–invasive treatments. Pain results due to hepatic cysts, renal cysts, and mechanical musculoskeletal changes . An understanding of the source of the patient’s pain is essential in helping to guide treatment. Causes for renal pain like cyst hemorrhage, infection, and urolithiasis must be looked for and treated. There are effective surgical procedures that can target pain due to renal cysts when more conservative treatments fail. Laparoscopic cyst decortication has been well studied and results in the relief of chronic renal pain in the majority of patients. For a successful cyst decortication, cysts need to be addressed on all surfaces of the kidney. To decorticate all cysts, the kidney needs to be extensively mobilized and often requires exploration of the renal hilum and nephropexy. With access to the renal hilum, a surgeon could readily perform a renal denervation procedure concurrently with cyst decortication to further address renal pain.
Nerve fibers join the renal artery at different points along its course, so an understanding of the complex anatomy of renal innervation in relation to the aorta, renal artery, and kidney can help guide a surgeon where to perform the denervation. In addition, there is evidence of different densities of nerve fibers along different aspect of the renal artery that could guide certain areas to focus on during the denervation procedure. The nerve fibers run circumferentially around the renal artery, but there is a trend for a higher nerve density on the ventral aspect of the renal artery, with nerve fibers that are more numerous and further from the lumen of the artery on more proximal segments.
While nephrectomy can successfully treat renal pain in patients with ADPKD, other treatment options should be utilized in patients with preserved renal function to prevent the need for dialysis or renal transplantation. Bilateral nephrectomy remains the treatment of choice in patients with end-stage renal disease. If the patient is going to receive a renal transplant, there are decreased perioperative complications by performing a renal transplant with unilateral nephrectomy followed by laparoscopic unilateral nephrectomy compared to a renal transplant followed by bilateral laparoscopic nephrectomy.
Written by:
Matthew W. Tellman, Clinton D. Bahler, and Chandru P. Sundaram as part of Beyond the Abstract on UroToday.com. This initiative offers a method of publishing for the professional urology community. Authors are given an opportunity to expand on the circumstances, limitations etc... of their research by referencing the published abstract.
Department of Urology, Indiana University School of Medicine, Indianapolis, IN USA
Management of pain in ADPKD and anatomy of renal innervation - Abstract