The efficacy of unilateral laparoscopic nephrectomy in the pediatric hypertensive patient.

BACKGROUND

Secondary hypertension due to a poorly functioning or non-functional kidney may be refractory to medical management. In such cases, nephrectomy can improve or cure hypertension. With the routine use of laparoscopy, nephrectomy can be performed in a minimally invasive manner, but surgery still carries inherent risks and complications.

OBJECTIVE

The objective of this study is to evaluate the outcomes of laparoscopic nephrectomy performed for secondary hypertension and identify potential predictors of postoperative hypertension resolution.

METHODS

After obtaining approval from institutional review board, patients from January 2002 to March 2018 who underwent laparoscopic nephrectomy were identified using Current Procedural Technology codes. All charts were then manually reviewed to isolate those patients with secondary hypertension present preoperatively. Patient demographics, urologic history, and laboratory and imaging findings were recorded for all patients. Serial blood pressures were recorded at all renal visits along with any antihypertensive medication changes. Postoperative outcomes and complications were also noted for all patients.

RESULTS

A total of 20 patients (7 girls, 13 boys) underwent laparoscopic nephrectomy to treat hypertension at an average age of 10.6 years (range 1.7-17.0 years). Etiology of a solitary non-functional kidney was vesicoureteral reflux in 10 of 20 patients, multicystic dysplastic kidney in 5 of 20, ureteropelvic junction obstruction in 2 of 20, ureteral obstruction in 1 of 20, and renal artery stenosis in 2 of 20 patients. At time of surgery, 3 of 20 patients were on two antihypertensives, 10 of 20 were on one antihypertensive, and 7 of 20 proceeded to surgery with no medical management. In the 30-day postoperative period, no complications were noted. Hypertension improved in 10 of 20 (50%) patients, all of whom were not on any antihypertensive medications after surgery. Hypertension persisted in 4 of 20 (20%) patients, requiring the same antihypertensive regimen and worsened in 6 of 20 (30%) patients, requiring increased doses and/or additional antihypertensives. Average follow-up time was 2.7 years. No significant predictors of postoperative hypertension result were identified when comparing the groups of responders and non-responders.

DISCUSSION

While laparoscopic nephrectomy for a non-functioning kidney in the setting of hypertension is a safe procedure, the cure rate for hypertension in the cohort appears to be on the low side of what was previously reported. While the small sample size is a main limitation, it is among the largest sample sizes for pediatric hypertensive patients. Previously shown predictors were not predictive in the similar-sized cohort.

CONCLUSIONS

Patients should be carefully counseled on the risks and benefits of nephrectomy to treat hypertension, the importance of continued follow-up after nephrectomy, and the possible need for chronic medical management with antihypertensives.