Renal cyst has become popular in the population due to the development of imaging technology and health insurance on screening [4, 5]. Renal cyst is usually one of most common medical conditions with no symptoms. Only a few patients have symptoms such as pain, hypertension, hematuria, recurrent urinary tract infection and even cyst rupture [6, 7]. According to Bosniak classification, the renal cysts can be classified as simple cysts (Bosniak grade I and II) or complex cysts (Bosniak grade III and grade IV). In practice for patients with simple renal cyst (Bosniak grade I and grade II), if the maximum diameter of cyst is less than 4 cm with no obvious clinical symptoms, the patient is usually advised regular follow-up. If the maximum diameter of the renal cyst is over 4 cm with obvious renal parenchymal damage on imaging, and with clinical symptoms and hematuria, the patient can be offered to undergo surgical removal. It aims to prevent further progression of the disease or further potential damage to the kidney function. There are many treatment options, such as ultrasound-guided puncture drainage plus hardener agent injection [8], traditional open surgery for decortication of renal cyst, laparoscopic decortication renal cyst surgery, flexible ureteroscopic management of renal cyst [9, 10] and percutaneous decortication renal cyst surgery [11].
Laparoscopic renal cyst decortication has the characteristics of less trauma, faster recovery, and better efficacy. It has become a preferred treatment option, especially for young patients with large cyst [12]. A comparative study between retroperitoneal approach and peritoneal approach demonstrated the retroperitoneal approach has significantly shorter operative time than the peritoneal approach. Moreover, the retroperitoneal approach may reduce the interference to the intestinal tract with significantly shorten the recovery time of intestinal function [13]. With the concepts of accelerated rehabilitation surgery and postoperative pain-free surgery developing in practice, the ambulatory surgery has become popular in hospital because of its simplified and standardized process of admission, diagnosis, treatment, and discharge. It seems can also relief the shortage of medical resource effectively [14, 15]. In the study, postoperative bowel function was restored before discharge in the day ward group. We attributed to the retroperitoneal approach protecting the peritoneum and the standardized cooperation process from the postoperative management team. In the case of infected cysts, the retroperitoneal approach may also reduce the incidence of peritoneal spread [16, 17].
The infections of catheter-related urinary tract had been reported increasing with each additional day of catheter retention [18]. Since the hospital stay in day surgery would not exceed 24 hours with the increase of the turnover rate; it may reduce the indwelling time of urinary catheters, and may also reduce the incidence of nosocomial infections. If postoperative infection occurs, an appropriate antibiotic can be prescribed in outpatient clinic according to the results of bacterial culture from samples. Including the postoperative complication rate from our study, there is no significant difference between two groups in comparison of the surgery related outcomes (operation time, intraoperative blood loss, 10–12 months of postoperative follow-up for renal cyst recurrence, postoperative quality of life score, and postoperative satisfaction rate). However, both the total hospitalization time and the time of postoperative drainage tube indwelling are significantly shortened, which reduces the medical expenses and health resources need.
Appropriate patient candidate selection and adequate preoperative assessment and preparation can be critical for prerequisites for the success of the day surgery [19, 20]. Therefore, for the patient safety, our procedures of laparoscopic decortication were tested in unilateral simple renal cyst under following requirements: ① The operator has skilled to the procedure with over 15-year experiences. ② All patients’ preoperative ASA assessment was I or II without other contraindications for operation and anesthesia. ③ Their Bosniak grades was restricted in the categories of I or II. Furthermore, the location, size and number of renal cysts as well as the relationship between renal cysts and peripheral vessels and renal collecting system were carefully analyzed by the operator according to preoperative ultrasound and CT examination. ④ The standardized cooperation process protocols from the postoperative management team can timely assess postoperative pain, intestinal function, and drainage. ⑤ The postoperative management team scheduled postoperative exam process timely, like CT scan and blood test. ⑥ Every postoperative patient was evaluated by the team at the time of discharge according to enhanced recovery after surgery criteria. Antecedents to recovery, the time required to recover, support and encouragement, regular appropriate information, and setbacks during recovery were all thought to affect the recovery process in positive or negative directions.
This study has several limitations. It was a prospective investigation, a single-center and case-controlled study. All cases were limited to simple and unilateral renal cyst cases with several other limitations, we cannot conclude if it is still safe and effective in other situations, like bilateral renal cyst, other Bosniak grades, or even complicated renal cyst under day surgery mode. Therefore, further investigations and large-size study may be required to confirm if patients with surgically-indicated renal cysts have benefit from the day ward mode.
Therefore, we suggested retroperitoneal laparoscopic unilateral simple renal cyst decortication is safe and feasible in the day ward model for patients who have appropriate conditions according to the inclusion standards in our study. It may reduce the need of our limited medical resources, reduces the possibility of urinary tract infections, and shortens patient’s hospital stay. Day surgery is considered to be a high-quality, safe, and cost-effective surgical mode, which requires clinicians to continuously explore and accumulate evidences in practice. During the implementation of day surgery mode, we believe it can improve medical quality with reducing medical costs in renal cysts in ambulatory surgery, which eventually benefits both patients and clinicians. In addition, for the current prevention and control of the COVID-19 pandemic, day surgery mode could be one of the best options suitable for patients with reduced hospital-stay time and protective supplies cost.