BJU International (1999), 83, 944–947

Changes in urinary output during laparoscopicadrenalectomyS. NISHIO, H. TAKEDA and M. YOKOYAMADepartment of Urology, Ehime University School of Medicine, Ehime, Japan

Objective To better understand the physiological eCects and significantly increased after desuAation. However,there were no changes in urinary output in patientsof pneumoperitoneum, by examining changes in uri-

nary output during gaseous and gasless laparoscopic who did not receive gas.Conclusion For the safety of laparoscopic surgeryadrenalectomy.

Patients and methods Laparoscopic adrenalectomy was it is important to recognise that oliguria occursduring pneumoperitoneum, although the changes inperformed with gas in six patients and without in

three. Urinary output was measured during urinary output caused no complications in renalfunction.insuAation and after desuAation.

Results In all patients who received gas, the urinary Keywords Pneumoperitoneum, oliguria, laparoscopicadrenalectomyoutput was significantly decreased during insuAation

Among the nine patients, six (four men and two women)Introduction

underwent laparoscopic adrenalectomy with CO2

pneu-moperitoneum and three (one man and two women)The technical advances of laparoscopic instrumentation

in the field of urology have been remarkable. underwent gasless laparoscopy. All nine patients hadnormal renal function and no history of systemic illnessLaparoscopic techniques have been introduced into vari-

ous kinds of surgeries, e.g. nephrectomy and adrenalec- aCecting the kidney. The operative duration was 210–320 min and the maximum intra-abdominal pressuretomy [1–3]. Despite reports of successful laparoscopic

procedures, especially nephrectomy and adrenalectomy, was set at 10 mmHg.Three factors were measured during each operation:there is concern about the potential for complications,

particularly physiological complications under pneumop- the urinary output by Foley catheter drainage, the bloodpressure and end-tidal CO

2concentration (PaCO

2).eritoneum, mainly aCecting the cardiovascular and pul-

monary systems [4–7]. Urinary volume was measured at the time of insuAation,every hour after its initiation and every hour after theThe increasing complexity of therapeutic laparoscopic

procedures requires longer periods of peritoneal end of insuAation, for a few hours. All patients receivedlactate Ringer’s solution intravenously during surgeryinsuAation than in previously reported procedures. The

safety of such lengthy laparoscopic procedures is thus (mean 350 mL/h). Serum creatinine was measured beforeand after surgery in all patients, and in one patient (no.questioned. Recently, oliguria and even anuria have

been found in animal models during conditions of high 5) it was also measured every hour during surgery. Thepatients’ characteristics are shown in Table 1.intra-abdominal pressure by pneumoperitoneum [8,9].

Thus we examined urinary changes in patients under- When gasless laparoscopic adrenalectomy was per-formed, the laparoscope was inserted through the uppergoing laparoscopic adrenalectomy to better understand

the clinical problem. margin of the umbilicus by open laparotomy. To createa workable space, 1.2 mm Kirschner wires wereadvanced subcutaneously below the costal arch and

Patients and methodsalong the upper portion of the laparoscope. The pairedt-test was used for the statistical analysis.Between October 1993 and March 1998, laparoscopic

adrenalectomy was performed using a transperitonealapproach in five men and four women (age range

Results46–57 years). The clinical diagnosis was cortical aden-oma in one patient and primary aldosteronism in eight. The mean hourly urinary output during surgery with

and without gas are shown in Fig. 1. The urinary outputdecreased significantly during the first hour of insuAationAccepted for publication 23 February 1999

944 © 1999 BJU International

CHANGES IN URINARY OUPUT DURING LAPAROSCOPIC ADRENAL ECTOMY 945

Table 1 Characteristics of patients undergoing laparoscopic transperitoneal adrenalectomy

Patient no. Type of Operative Estimated bloodage/sex Side Original disease surgery time (min) loss (mL) Complications

1 46/M R PA Gas 320 100 None2 49/M L PA Gas 310 250 None3 57/F L PA Gas 340 100 None4 52/F R PA Gas 210 50 None5 48/M L PA Gas 300 50 None6 52/M L Cortical adenoma Gas 240 100 None7 47/M L PA Gasless 260 150 None8 50/F L PA Gasless 330 100 Ileus9 50/F L PA Gasless 270 50 None

PA, primary aldosteronism.

Pren = 6

h

1n = 6

2n = 6

3n = 6

4n = 3

Uri

nar

y vo

lum

e (m

L/h

)

100200300400500600700800

01

h

2 3 4 5

Uri

nar

y vo

lum

e (m

L/h

)

50

100

150

200

250

300

0

a b

**NS

***

1(off)n = 6

2(off)n = 6

3(off)n = 4

Fig. 1. The mean (sd) changes in urinary output during laparoscopic surgery, a, with gas and b, without gas. The urinary outputdecreased significantly during the first hour of insuAation (P<0.05) and increased significantly after desuAation in patients whounderwent surgery with gas (P<0.1). There was no change in urinary output in patients without gas. (*P<0.05, **P<0.1)

progressed. Overall, in the patients who received gas,urinary output increased significantly after stoppinginsuAation and was 70–600 mL/h. The degree of oliguriawas not related to sex, or location of the adrenal tumours.

The serum creatinine level did not change from theday before to the day after surgery in any patient whoreceived gas. In patient no. 5, the level was measuredin detail; the level increased during the second hourafter insuAation and continued to increase for 1 h afterdesuAation (to 16 mg/L), the level returning to normalthe next day.

1 2 3 4 5 1(off)

Nextday

0

Ser

um

cre

atin

ine

(mg

/L)

8

10

12

14

18

16

20

6

hChanges in PaCO

2during surgery with gas were also

Fig. 2. Changes in serum creatinine levels during and after surgeryexamined, but there was no relationship between urinaryin patient no. 5.output and the level of PaCO

2. Blood pressure increased

by #20 mmHg in all six patients who underwent CO2(P<0.05) and increased significantly after desuAation in

pneumoperitoneum after insuAation and returned topatients who underwent surgery with gas (P<0.1). Therenormal immediately after desuAation.was no such tendency toward decrease in urinary output

in patients without gas. There were various patterns ofDiscussiondecrease in urinary output in patients during insuAation.

In patients nos 2 and 3, severe oliguria occurred during There has been no previous report detailing urinaryoutput during laparoscopic adrenalectomy with pneumo-the first hour after insuAation. In patient no. 5, the

urinary output gradually decreased as the surgery peritoneum or without gas. In the present series, in

© 1999 BJU International 83, 944–947

946 S. NISHIO et al.

patients with gas, the urinary output decreased during systems, like those associated with Cushing syndrome, andcardiovascular disturbances like phaeochromocytoma.pneumoperitoneum but these changes caused no compli-

cations in renal function. Chang et al. [10] noted oliguria In conclusion, changes in urinary volume were sig-nificant during gaseous but not gasless laparoscopy.during laparoscopic surgery in their series of six patients

(cholecystectomy in five and pelvic lymphadenectomy in These results suggest that monitoring urinary volumemay be important for increased safety during laparos-one). Chiu et al. [9] showed oliguria in an animal model

after gaseous insuAation during peritoneal or retroperi- copy, particularly during lengthy procedures. Specialattention should be given to patients with insuBcienttoneal insuAation, but not after lifting the abdominal

wall. They also noted that creatinine clearance declined, renal function. The amount of fluid infused should becarefully considered, especially during insuAation, evenwhereas the clearance rates of potassium, sodium and

urea remained unchanged. Richards et al. [11] reported if the urinary output is very low. Laparoscopic surgerywithout gas (the lifting method) can be an option forthat an abdominal pressure of > 15 mmHg induced

oliguria and that pressures of > 30 mmHg induced patients with renal insuBciency.anuria. The renal eCects of pneumoperitoneum are prob-ably related to renal vascular insuBciency from centralvenous compression [8]. In addition, it has been reported Referencesthat direct compression of the renal parenchyma in 1 Higashihara E, Tanaka Y, Horie S et al. Laparoscopicpatients decreased the tissue perfusion of the superficial adrenalectomy: the initial 3 cases. J Urol 1993; 149: 973–6cortex during pneumoperitoneum, and that renal cortical 2 Takeda M, Go H, Imai T, Nishiyama T, Morishita H.perfusion markedly decreased to half the level before Laparoscopic adrenalectomy for primary aldosteronism:

report of initial ten cases. Surgery 1994; 115: 621–5insuAation after peritoneal insuAation, to a pressure of3 Terachi T, Matsuda T, Terai A et al. Transperitoneal15 mmHg [12]. Previous investigators have found an

laparoscopic adrenalectomy: experience in 100 patients.increase in plasma antidiuretic hormone levels withJ Endourol 1997; 11: 361–5increased abdominal pressure in dogs [13].

4 Wersterband A, Joseph MDW, Amzallag M et al.Complications related to the respiratory and circulat-Cardiovascular changes during laparoscopic cholecystec-ory systems have been reported with pneumoperitoneumtomy. Surg Gynecol Obstet 1992; 175: 535–8

[4,6]. Increased plasma renin activity has been recorded5 Gill IS, Kavoussi LR, Clayman RV et al. Complications of

during pneumoperitoneum in rats [14]. Recently, laparoscopic nephrectomy in 185 patients: a multi-Mikami et al. [15] showed catecholamine release caused institutional review. J Urol 1995; 154: 479–83by CO

2insuAation in 29 patients. Carbon dioxide pneu- 6 Wolf JS, Stoller ML. The physiology of laparoscopy: basic

moperitoneum produces variable degrees of hypercapnia. principles, complications and other considerations. J Urol1994; 152: 294–302Excessive hypercapnia may result in cardiovascular

7 Matsuda T, Terachi T, Yoshida O. Laparoscopy in urology:depression and even cardiac arrest. Oliguria was associ-present status, controversies and future directions. Intated with pneumoperitoneum in the present patients,J Urol 1996; 3: 83–97although there were no problems related to the respirat-

8 Kirsch AJ, Kayton ML, Hensle TW, Olsson CA, Change DT,ory and circulatory systems. Oliguria or anuria duringSawczuk IS. Renal eCects of CO2 insuAation: oliguria andpneumoperitoneum appears inevitable. It is not onlyacute renal dysfunction in a rat pneumoperitoneum model.

futile to hydrate the patient to increase urinary outputUrology 1994; 43: 453–9

during gaseous laparoscopy, but it may even be 9 Chiu AW, Chang LS, Birkett DH, Babayan RK. Changes inhazardous to overhydrate patients with a poor cardiac urinary output and electrolytes during gaseous and gaslessperformance status. laparoscopy. Urol Res 1996; 24: 361–6

Gasless laparoscopy provides an attractive alternative 10 Chang DT, Kirsch A, Sawczuk IS. Oliguria during laparo-scopic surgery. J Endourol 1994; 8: 349–52to insuAation [16]. It allows the use of traditional

11 Richards WO, Scovill W, Shin B, Reed W. Acute renalinstruments and the performance of complex surgicalfailure associated with increased intra-abdominal pressure.manoeuvres such as free suction and suturing. ThereAnn Surg 1983; 197: 183–7have been no complications related to pneumoperi-

12 Chiu AW, Azadzoi KM, Hatzichristou DG, Siroky MB, Kranetoneum. One disadvantage of gasless laparoscopy is thatRJ, Babayan RK. ECect of intra-abdominal pressure onthe lifting arm and devices sometimes disturb the operat-renal tissue perfusion during laparoscopy. J Endourol 1994;

ive techniques. In the present series, there were no8: 99–103

diCerences between gasless and laparoscopic adrenalec- 13 Roith DL, Bark H, Nyska M, Glick SM. The eCect oftomy with pneumoperitoneum in operative duration, abdominal pressure on plasma antidiuretic hormone levelsblood loss or postoperative hospitalization. Gasless in the dog. J Surg Res 1982; 32: 65–9laparoscopic adrenalectomy is safe and suitable for 14 Diebel LN, Wilson RF, Dulchavsky SA, Saxe J. ECects of

increased intra-abdominal pressure on hepatic arterial,patients with renal insuBciency, poor respiratory

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CHANGES IN URINARY OUPUT DURING LAPAROSCOPIC ADRENAL ECTOMY 947

portal venous, and hepatic microcirculatory blood flow. AuthorsJ Trauma 1992; 33: 279–85 S. Nishio, MD, Associate Professor of Urology.

15 Mikami O, Kawakita S, Fujise K, Shingu K, Takahashi H, H. Takeda, MD, Assistant Professor of Urology.Matsuda T. Catecholamine release caused by carbon dioxide M. Yokoyama, MD, Professor of Urology.insuAation during laparoscopic surgery. J Urol 1996; Correspondence: Dr S. Nishio, Department of Urology, Ehime155: 1368–71 University School of Medicine, Shigenobuocho, Ehime,

16 Moriya K, Sakakibara N, Hirakawa K et al. Clinical study 791–0295, Japan. e-mail: nishio@m.ehime-u.ac.jp.of gasless laparoscopic adrenalectomy in 17 cases. JpnJ Urol 1997; 88: 1021–7

© 1999 BJU International 83, 944–947