JOURNAL OF ENDOUROLOGY

Volume 25, Number 3, March 2011

ª Mary Ann Liebert, Inc.
Pp. 471–476
DOI: 10.1089=end.2010.0254

Is It Safe and Effective to Treat Complex Renal Cysts

by the Laparoscopic Approach?

Thomé Pinheiro, Jr., M.D., Fabio Sepulveda, M.D., Ricardo H. Natalin, M.D.,
Esteban Metrebian, M.D., Rebecca Medina, B.S., Suzan M. Goldman, M.D.,
Valdemar Ortiz, M.D., Ph.D., and Cássio Andreoni, M.D., Ph.D.

Abstract
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Background and Purpose: Bosniak III and IV renal cysts have low mortality potential, and little is reported
regarding the feasibility and safety of managing such tumors by laparoscopy and its comparison with open
surgery. We report on the experience with 37 complex renal cysts managed in the era of laparoscopy.
Patients and Methods: A retrospective analysis of a prospective database from all patients with renal tumors
who were operated on at our institution was evaluated after Institutional Review Board approval. The database
comprises information for demographic, clinical, imaging, preoperative, intraoperative, histologic, and follow-
up data. A comparison among all performed approaches was done for demographic, American Society of
Anesthesiologists classification, operative time, estimated blood loss, ischemia time, hospital stay, oncologic and
survival rate. The cysts removed by laparoscopic partial nephrectomy were compared with the solid tumors
removed by the same approach at the same period.
Results: The database included 407 patients with renal tumors who were operated on from 2000 to 2009 at our
institution. In 36 patients of the total cohort, there were 37 complex renal cysts. No patients with preoperative
Bosniak type I or II underwent surgery. Of the cysts, 60% were Bosniak IV, and 86% were confirmed as
malignant; 40% were Bosniak III, and 44% were confirmed as malignant. Laparoscopic partial nephrectomy was
performed in 67.5%. The tumor size and hospital stay were significantly different in the laparoscopic group. No
cyst spillage occurred either by laparoscopy or by the open approach, and no tumor recurrence was found in a
mean follow-up of 43.7 months with overall survival of 100%.
Conclusion: Laparoscopic surgery for complex cysts is safe, feasible, and effective. Nevertheless, regardless
of surgical approach, patients with complex renal cysts have excellent overall survival with short-term follow-up.

Introduction
T he discrimination between benign renal cysts and
those that have a greater risk for malignancy necessitat-
ing surgical removal has become easier with the acceptance of
the Bosniak renal cyst classification by urologists and radiol-
ogists in the past decades.1 The best surgical approach for
complex renal cysts, however, remains controversial because
of the little reported data and also because cystic masses may
burst during surgical manipulation with potential tumor cell
spillage. Nevertheless, complex renal cysts present favorable
biologic behavior with high rates of overall patient survival
when removed,2,3 and such patients have benefits with
nephron-sparing surgery (NSS).4 Spaliviero5 and associates
reported on the surgical outcomes of laparoscopic partial
nephrectomy (LPN) for suspicious cystic masses and con-
cluded that this approach is similar to those of LPN for solid
tumors; the authors pointed out that extreme caution and
refined laparoscopic technique must be exercised to avoid
cyst rupture and local spillage during surgical manipulation.
There is no previously reported data evaluating the lapa-
roscopic approach and conventional open surgery for com-
plex renal cysts in a contemporary series when laparoscopy is
used more often.6 We report on the evaluation of 37 complex
renal cysts that were managed in the era of laparoscopy.
Patients and Methods
A prospective database that collects data from all patients
with renal tumors operated on at our institution since 2000
was retrospectively evaluated, and data from patients oper-
ated on because of complex renal cysts was retrieved. The
database comprises information with demographic, clinical,
imaging, preoperative, intraoperative, histologic, and follow-up

Division of Urology, Federal University of São Paulo, São Paulo, Brazil.

471
 472
data, and it was previously approved by the Institutional
Review Board.
Imaging
All patients undergoing the surgery had either a CT scan or
MRI or both. The radiologist who works in the division of
urology at our institution reviewed the imaging data, and if
necessary, the test was repeated at our institution for a more
accurate evaluation; then, the image data were used for Bos-
niak renal cyst classification.1
Indications of surgical approach
The patients with complex renal cysts were evaluated by
the same urologic team in the period, and only patients with
Bosniak types III and IV classified after radiologic review
were considered candidates for surgical removal. Patients
with neither Bosniak type I nor type II=IIF underwent sur-
gery. NSS was favored for most patients, regardless of tumor
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size or absolute indications, such as solitary kidney, renal
insufficiency, and bilateral tumor. Radical nephrectomy was
recommended when the renal cyst was invading the renal
hilum such that it would not be possible to perform NSS; one
patient with von Hippel Lindau disease had a complex lesion,
and surgery was performed partial nephrectomy after lapa-
roscopic radical nephrectomy with donor technique (Fig. 1).
Open surgery was only considered in patients with absolute
contraindications, such as cardiac and lung diseases. Open
partial nephrectomy (OPN) was also considered for patients
with complex hilar tumors when ischemia time was expected
to be longer than 30 minutes.
FIG. 1. (A) CT showing renal cyst Bosniak IV; (B) laparoscopic radical nephrectomy; (C) ex-vivo partial nephrectomy; (D)
final aspect of the kidney after surgery; (E) postoperative renal scan with good function in the pelvis.
PINHEIRO ET AL.
Surgical techniques
LPN was offered as a first option when possible; four tro-
cars were placed transperitoneally; intraoperative ultraso-
nography was performed only for precise localization; a
bulldog clamp was placed in both artery and vein (warm
ischemia); and the tumor was removed with endoshears and
intracorporeal suturing performed for hemostasis (Fig. 2).
Laparoscopic radical nephrectomy was performed trasn-
speritoneally with four trocars in a standard fashion and the
specimen removed through a suprapubic incision. OPN was
performed retroperitoneally, and cold ischemia was per-
fomed in all cases (Fig. 3). Open radical nephrectomy was
performed retroperitoneally in a standard fashion.
Findings of patients with Bosniak III and IV renal cysts who
underwent surgical cyst removal were evaluated. A com-
parison among all the approaches was performed for demo-
graphic, American Society of Anesthesiologists classification,
operative time, estimated blood loss, ischemia time, hospital
stay, oncologic and survival rate. The cysts removed by LPN
were compared with the solid tumors removed by the same
approach at the same period.
Statistical analysis was performed for numerical measures
using the Student t test, and significance was considered
when P < 0.5.
Results
From 2000 to 2009, 407 renal tumors were removed in the
division of urology at our institution, and 37 tumors were
classified as Bosniak type III and IV in 36 patients; one pa-
tient had complex cysts bilaterally. The radiologic analysis of
 SURGICAL APPROACHES TO COMPLEX CYSTS 473
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FIG. 2. (A) CT showing a Bosniak IV cyst; (B) gross appearance of the lesion after resection (renal-cell carcinoma); (C) in-
traoperative ultrasonography showing the details of the tumor for a safe complete resection; (D) laparoscopic partial nephrectomy.

37 complex cystic lesions according to the Bosniak classifi-
cation revealed that 15 were type III and 22 were type IV.
Twenty-two tumors were on the right side and 15 on the left
in 24 men and 12 women. Demographic data are shown in
Table 1.
LPN, OPN, laparoscopic radical nephrectomy, and open
radical nephrectomy were performed in 67.5%, 10.8%, 10.8%,
and 8.1%, respectively. Table 2 shows the perioperative data
for all the surgeries performed for complex renal cysts. The
tumor size and hospital stay were significantly different in the

FIG. 3. (A, B) MRI showing complex renal cyst Bosniak III because of cystic wall enhancement; (C) open partial ne-
phrectomy; (D) gross appearance of cystic nephroma.
 474 PINHEIRO ET AL.

Table 1. Demographic Data group of lesions showed that 64.8% of all complex cysts were
malignant lesions; the multicystic renal-cell carcinoma ac-
Patients (n) 36 counted for 91.6% of the tumors, and only two (8.3%) tumors
Cysts (n) 37
were papillary. Bosniak IV cysts were malignant in 86.2% of
Age (y) 55 (33–80)
BMI (kg=m2) 26.1 (22–37) the time; the three benign lesions were one oncocytoma with
Sex, male 66.6% (24) cystic component and two multicystic nephromas. The Bos-
ASA 1 n (%) 30.5% (11) niak III cysts were benign in 66% of cases, comprising six
ASA 2 n (%) 55.5% (20) benign cysts and four multicystic nephromas. We did not
ASA 3 n (%) 13.8% (5) observe involvement of surgical margins or rupture of the
Follow-up (mos) 52.2 (2–114) cysts in our series independent of surgical technique. The
Right side 61.2% (22) malignant lesions were staged clinically and pathologically
according to the tumor-node-metastasis system 2002; 50%
BMI ¼ body mass index; ASA ¼ American Society of Anesthesiol-
ogists. were pT1a, seven (29%) tumors were pT1b, and five pT2. More
than half of the tumors were Fuhrman grade 1, 40% Fuhrman
grade 2, and only one (4.1%) tumor had Fuhrman grade 3. No
specimen showed vascular embolization. At mean follow-up
laparoscopic group. There were no conversions. There was no
of 43.7 months (range 2–104 mos), there were no recurrences
involvement of surgical margins or violation of the cysts
of the disease regardless of histologic type, staging, and sur-
during the procedures. No cyst spillage occurred either by
gical modality used.
laparoscopy or by the open approach, and no tumor recur-
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The comparison of LPN for complex cysts with solid tu-

rence was found in the mean follow-up of 43.7 months with
overall survival of 100% (Table 3).
Major complications occurred in two cases after LPN and
one case after OPN. Two patients after LPN with persistent
hematuria after 7 and 10 days underwent selective renal
embolization because of arteriovenous fistula. Acute tubular
nechrosis with renal insufficiency developed in one patient
after OPN, and the patient underwent temporary dialysis.
Four patients underwent OPN; one had a 14-cm complex cyst
in the lower pole of one kidney, and two patients presented
hilar cysts leaning and touching the renal vessels. Another
case was discovered incidentally during an episode of acute
diverticulitis and operated on at the time of colostomy clo-
sure.
Radical nephrectomy was performed in seven (18.9%)
cases. The laparoscopic approach was recommended in four
cases; one patient, in spite of having a 4-cm cyst, had end-
stage renal disease; the other patients had renal cysts with an
unfavorable location for NSS. Open radical nephrectomy was
performed in only three patients with hilar tumors with av-
erage size of 6.2 cm and with clinical contraindication to
pneumoperitoneum because of cardiac diseases.
Table 3 shows the histopathologic data. The size of the cysts
surgery ranged from 1.5 to 14 cm. Histologic analysis of this
mors (Table 4) revealed no significant difference regarding the
variables evaluated; the operative time, warm ischemia time,
and intraoperative bleeding were slightly higher in the group
of complex cysts, but there was no statistical significance.
Discussion
Despite the limitations from a retrospective study, in the
present series, a similar histologic profile was observed as has
been reported in other series of complex cysts, but with a
higher rate of benign lesions in the group of Bosniak type III
cysts.5,7 Historically, several studies have shown that the
complex cysts have low mortality potential, represented
mainly by multicystic renal-cell carcinoma, small size, early
stage, low-grade malignancy, and papillary tumors 2–5,7 with
characteristics similar to those of incidental renal tumors less
than 4 cm.8 Based on this fact, if one extrapolates the knowl-
edge gained with tumors smaller than 4 cm, cystic tumors
have a similar biologic behavior, and patients may have dis-
ease-free survival at 5 years of 90% to 100% when treated with
NSS.9–11
Little is known about the natural history of complex cysts
and Corica and colleagues3 suggested NSS as the ideal ther-
apeutic modality in the management of complex renal cysts.

Table 2. Perioperative Results

Partial Radical

Laparoscopic Open P value Ex-vivo Laparoscopic Open P value

n 25 4 1 4 3
Age (years) 54.0 (33 = 80) 54.0 (39-79) 0.67 41 53.7 (49–63) 62.0 (52–69) 0.2
ASA classification 11=12=02 0=0=3 0=2=0 1=3=0 0=0=3
I=II=III
Size (cm) 3.5 (1.5–10.0) 8.2 (3.0–14.0) 0.00 10.5 6.7 (4.0–10.0) 6.1 (3.2–9.2) 0.7
Malignant % (n) 52% (13) 75% (3) 0.5 100% (1) 100% (4) 100% (3)
Pt1a=1b=T2 11=2=0 1=2=1 0=0=1 1=2=1 1=1=1
Operative time (min) 168 (90–240) 135 (90–210) 0.3 240 195 (150–270) 140 (120–60) 0.1
Estimated blood 346 (50–1000) 462 (150–1000) 0.39 300 462 (50–1500) 433 (300–500) 0.9
loss (mL)
Ischemia time (min) 30 (20–45) 27 (15–48) 0.32 – – – –
Hospital stay (days) 2.7 (2–5) 5.0 (4–6) 0.00 4 2.2 (2-3) 5.6 (3–9) 0.07
 SURGICAL APPROACHES TO COMPLEX CYSTS 475

Table 3. Histopathologic Results

Bosniak III Bosniak IV Total

Size (cm) 4.3 (1.5–12) 4.0 (1.5–14) 4.19 (1.5–14)

n Histology 15 22 37
%
RCC multicystic 5 17 22
33.3% 77.2% 59.4%
RCC papillary 2 2
9.0% 5.4%
Oncocytoma 1 1
4.5% 2.7%
Benign cyst 6 6
40.0% 16.2%
Cystic nephroma 4 2 6
26.0% 9.0% 16.2%
TNM 2002
pT1a 4 8 12
80.0% 42.1% 50.0%
pT1b 1 6 7
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20.0% 31.5% 29.1%

pT2 5 5
26.3% 20.8%
Fuhrman 1 4 9 13
grade 80.0% 47.3% 54.1%
2 1 9 10
47,30% 41,60%
3 1 1
5.2% 4.1%
Size (cm) 3.7 (1.5–10.0) 4.9 (1.6–14) 4.6 (1.5–14)
Vascular embolization 0 0 0
Follow-up (months) 60.4 (42–91) 37.0 (02–104) 43.7 (2–104)
Recurrence 0 0 0
Overall survival 100% 100% 100%

RCC ¼ renal cell carcinoma; TNM ¼ tumor node metastasis.

There was no tumor recurrence independent of tumor size,
stage, and number of cysts or disease-related mortality sur-
vival and tumor recurrence in 24 cases of cystic renal-cell
carcinoma that was surgically removed in a mean follow-up
of 77.6 months, suggesting that preserving as much func-
tioning renal tissue offers benefits to the patient without jeo-
pardizing the cancer treatment. Sharing the same opinion, the
present series elected partial nephrectomy as the modality of
choice in the management of complex renal cysts, and only
seven cases of complex renal cysts were candidates for radical
surgery because of their large size, anatomic complexity, and
lack of need for renal preservation.
The approach of choice for renal tumors in our institution is
the laparoscopic approach; 30 laparoscopic procedures (25
partial nephrectomies and 5 radical nephrectomies) were
performed. The open approach was selected for complex
cases; the selection criteria are based on size and location of
lesions, and candidates for open surgery were only those who

Table 4. Comparison Between Cystic and Solid Tumors

Cystic Solid P value

n 25 112
Size (cm) 3.5 (1.5–10) 3.3 (1.2–10) 0.6
Operative time (min) 168 (90–240) 165.8 (55–300) 0.7
Warm ischemia time (min) 30 (20–45) 28 (10–57) 0.3
EBL (mL) 346 (50–1000) 283 (25–2000) 0.3
Hospital stay (d) 2.7 (2–5) 2.9 (1–33) 0.5
Hilar tumor 28% (7) 24% (27) 0.5
Collecting system opening 44% (11) 47% (53) 0.6
Positive margins 0% (0) 1.7 (2)
Conversion to radical nephrectomy 0% (0) 2.67% (3)
Conversion to open aproach 0% (0) 0% (0)

EBL ¼ estimated blood loss.

 476
had large lesions, very close to the renal vessels, that would be
difficult to remove by laparoscopy and patients with absolute
contraindication to pneumoperitoneum.
Only 10.8% (4) of our patients underwent OPN; therefore,
25 (67.5%) patients were candidates for LPN in our series,
and no conversions were observed at the time of surgery,
with no significant differences when compared with other
historical series of partial nephrectomy for solid tumors of
the kidney.
The potential violations of the cysts during surgery did not
occur in the present study regardless of surgical approach,
and at a mean follow-up of 52.2 months, there were no re-
currences of the disease. In the series by Spaliviero and co-
workers,5 33 patients with complex cysts (Bosniak III and IV)
underwent the laparoscopic approach, and there was no vi-
olation or tumor involvement of tumor margins; only one case
of tumor recurrence occurred in a 2-cm Bosniak III cyst with
Fuhrman grade III. Limb and associates12 performed a lap-
aroscopic procedure in 57 complex cysts, called indeterminate
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cysts; they aspirated the fluid and biopsied the cystic wall at
operating time, which revealed that 20% were malignant. No
recurrences were observed in five patients who underwent
partial nephrectomy and six who underwent radical ne-
phrectomy in a mean follow-up of 40 months.
At present, renal ablation therapy, such as cryoablation and
radiofrequency ablation, would be a possibility for the man-
agement of a complex cystic lesion, but the likelihood of tu-
mor spillage during the probe placement and the unknown
best target to place the probe into the cyst made this approach
interesting but still not used in our institution.
Conclusion
Regardless of the low mortality potential, complex renal
cysts need a precise and complete surgical removal with
maximum renal parenchyma preservation, which can be of-
fered in a less invasive approach, such as LPN, without vio-
lating oncologic principles. Laparoscopic surgery for complex
cysts is safe, feasible, and effective. Nevertheless, regardless of
surgical approach, patients with complex renal cysts have
excellent overall survival.
Disclosure Statement
No competing financial interests exist.
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Address correspondence to:
Cassio Andreoni, M.D., Ph.D.
Department of Urology
Federal University of São Paulo
Rua Jesuino Arruda, 60
São Paulo-SP 04532-080
Brazil
E-mail: cassio.andreoni@globo.com
Abbreviations Used
LPN ¼ laparoscopic partial nephrectomy
NSS ¼ nephron-sparing surgery
OPN ¼ open partial nephrectomy