Between 2012 and 2020, 4 patients with HSK underwent heminephrectomy. Of these four patients, pure laparoscopic heminephrectomy was done in three patients while in one patient laparoscopic approach was converted to open approach in view of intra-operative bleeding. Data were retrospectively gathered from digital medical records. Computed tomography urogram (CTU) was done preoperatively and the split function was assessed with DTPA renogram. Laparoscopic surgery was performed via transperitoneal approach in all cases.
2.1 Case 1
A 30-year-old married female presented with right flank pain for past 2.5 months. Abdominal examination showed mass in right lumbar area. On ultrasound examination, lower pole could not be traced completely and appeared to go medially and therefore HSK was suspected with severe 4 ports (2 ports of 12 mm and another 2 ports of 5 mm) in right lateral position. 12-mm camera port was placed at umbilicus, 5 mm port in mid-clavicular line below right costal margin, 5 mm in right iliac fossa and one liver retractor port 7 cm below xiphoid process.
After colonic deflection and kocherization, dissection done at upper pole to move kidney away from liver. Multiple atretic vessels were noticed which were controlled with 10 mm Ligasure.
Demarcation between empty hydronephrotic sac and fleshy parenchyma was seen, and isthmus was transected with monopolar hook at this demarcation grade 4 hydronephrosis in right kidney. CTU confirmed HSK with right severe grade 4 hydronephrosis (Fig. 1a and b). DTPA scan showed 10.2% split function of right moiety. Initially right percutaneous nephrostomy (PCN) tube was passed under sonography guidance which drained approximately 700 ml of clear fluid. Subsequently she underwent laparoscopic right hemi-nephrectomy using line (Fig. 1c). Subsequent repair with 3–0 vicryl was done.
2.2 Case 2
A 40-year-old male presented with history of left flank pain for 6 months. He underwent left percutaneous nephrolithotripsy seven years back. On CTU HSK was confirmed along with enlarged left kidney with loss of normal architecture along with multiple enlarged para-aortic lymph nodes. No excretion of contrast was seen in 20 min delayed films (Fig. 2). Left laparoscopic heminephrectomy was attempted by transperitoneal approach with 4 ports placed. Dense adhesions were present with obliteration of tissue planes. After colonic reflection upper pole was freed from spleen by gradual adhesiolysis. Caudal to isthmus, uretero-gonadal packet was lifted from psoas, and posterolateral dissection was performed to lift the kidney from posterior abdominal wall. An inadvertent injury occurred in pelvis during dissection leading to pus spillage which was immediately suctioned out. Many aberrant vessels came across the dissection and were controlled with Hem-o-lok weck clips and Ligasure. While dissection around isthmus, injury to aberrant artery occurred which could not be controlled even with rescue stitch. Immediately open conversion was done, and bleeding was controlled followed by isthmectomy with monopolar cautery and the cut edges were sutured with 3–0 vicryl to achieve hemostasis. Surprisingly histopathological examination turned to be squamous cell carcinoma of renal pelvis with positive margin. Patient was advised for cisplatin-based chemotherapy and radiotherapy.
2.3 Case 3
A 44-year-old male was admitted with history of dysuria, fever with chills, right side flank pain and pyuria. Ultrasonography showed HSK with right severe grade 4 hydronephrosis. CTU revealed HSK with enlarged and severely grade 4 hydronephrotic right kidney (Fig. 3). DTPA scan showed split function of right kidney of 7%. Patient underwent laparoscopic right heminephrectomy. Ports were placed as in the first case. After colonic reflection two renal veins and one renal artery are seen entering kidney at hilum which were clipped with Hem-o-lok weck clips. Aberrant small vessels were dealt with 10 mm Ligasure. Huge hydronephrotic sac was decompressed with Veress needle. Isthmus was cut with Ligasure in direction more towards the right hydronephrotic kidney and thus avoiding left kidney parenchymal injury.
2.4 Case 4
A 34-year-old male presented with intermittent left flank pain with dysuria for nine months. The pain interfered with his activities of daily living. CTU revealed HSK with left side pelvic-ureteric junction obstruction (PUJO) causing severe grade 4 hydronephrosis (Fig. 4). Relative function on DTPA scan was 10.2%. Transperitoneal right laparoscopic heminephrectomy was performed using four ports. Spleen was moved away from upper pole and left ureter was divided below PUJ. A window created at cranial border of isthmus and main renal artery and lower polar accessary artery were clipped with Hem-o-lok clips. After vascular control posterolateral dissection was done. Isthmus was isolated and cut with bipolar scissor toward deflated hydronephrotic sac followed by suturing with V-loc sutures to combat edge bleeding.