The most important findings from this study were that patients with ADPKD who undergo native nephrectomy have good overall outcomes and it remains a safe surgical option. However, these patients had long hospital stays and a high rate of blood transfusion. The indications for surgery gathered from our study are consistent with the literature on native nephrectomies in patients with ADPKD [3, 12]. Of note, bleeding was the most common indication for surgery in our study, reported in 41.8% of patients. Transcatheter arterial embolization of the renal arteries (TAE) is a non-invasive procedure utilised in patients with symptomatic polycystic kidneys to help reduce kidney volume, pain and reduce bleeding [5, 13, 14]. It has been shown to be safe and effective in order to optimise patients for kidney transplantation [14]. Given the high rate of reported bleeding in our study, it shows that further research into TAE as an alternative approach to manage these patients is needed. A study by Akabane et al. investigates using TAE combined with nephrectomy [13]. This would have the added benefit of decreasing kidney size before nephrectomy allowing for easier access and potentially lower complications.

Although research into laparoscopic nephrectomies has shown favourable outcomes, even for massive kidneys, the majority of surgeries within our institution were performed using an open approach. The recommendation from the literature is for optimal choice to be made from the surgeon’s experience [5]. Our study reported no deaths in the immediate postoperative period. This is important to highlight as it demonstrates that open nephrectomy is still a safe procedure if required for patients. The centre where this study was performed is also the national centre for kidney transplantation. The surgeons operating in this centre are familiar with the open approach for transplant and nephrectomy. Although recent evidence does suggest that the laparoscopic approach may have more favourable outcomes, what is most important is surgeon experience; this is likely why majority of nephrectomies in ADPKD patients in our hospital were performed using the open approach. Our study shows that the open approach is still a safe operation to offer patients. The open approach has also been shown to have shorter operation times [15]; it is likely in some busy centres, where multiple specialties are competing for theatre space, that this may influence the surgeon’s choice of approach.

The average length of stay (LOS) in this study was 10.1 days. This is a comparable figure to other studies on open nephrectomy in ADPKD patients, with reports ranging from 6.5 to 12 days [3, 7, 16, 17]. The reported LOS after laparoscopic nephrectomy is significantly shorter in the literature, reported at 4–8 days [4, 16,17,18]. In a study published by Lubennikov et al., comparing the open with the laparoscopic approach for nephrectomies in ADPKD, they found a median length of stay for the open approach of 12.5 days [17]. They further broke their results into emergent and elective operations and found an elective LOS of 9 days and 16.5 for emergent operations. In our study, we did not further subdivide our groups into elective and emergent due to the risk of adding bias. Majority of these operations are performed with a certain level of urgency, especially with haemorrhage being the largest indication, we felt that separating these patients into groups retrospectively would add observer bias as to what was elective and what was an emergency and thus may create unreliable results. This likely explains are mean LOS of 10.1 days being on the higher range of that reported in the literature.

Our results found a malignancy rate of 7% among histology specimens. A recent systematic review by Drake et al. found a malignancy rate of 5.7% among patients with ADPKD [19]. Our results are consistent with the current literature regarding RCC in patients with ADPKD.

Blood transfusion in patients with ADPKD has been a widely debated topic for a number of years [20]. The literature would recommend minimising all transfusions in this population. This is due to HLA sensitization and the resultant effect it may have on future transplantation [20]. Current evidence would suggest that multiparous women, patients with previous allografts and patients who have received multiple blood transfusions in the past are most at risk of HLA sensitization after receiving a blood transfusion [20]. Administration of EPO and other blood-conserving treatments is essential to minimise transfusion. There is no specific guideline on transfusion thresholds in these patients postoperatively. Instead, a patient-specific approach is recommended by analysing all the above risks, along with other co-morbidities such as age, previous strokes or coronary artery disease [20]. Blood transfusions are classified as a grade 2 complication with the Clavien-Dindo Classification for postoperative complications [21]. This study reported 16 (37.2%) patients receiving a transfusion postoperatively. This is comparable to reports from other studies, ranging from 0 to 42.4% [10, 12, 22]. A study by Eng et al. found an overall postoperative transfusion rate for open nephrectomy in ADPKD patients of 41.7%, and another study by Verhoest et al. found a postoperative transfusion rate of 15.8% [23, 24]. Our study reports a rate of 37.2% which is consistent although on the upper range of what other studies have reported. It is clear that the rate of transfusion ranges quite significantly from one study to another, and this is likely due to the lack of consensus among transfusion targets in this population. It is clear that further research and consensus on blood transfusion in this population is necessary in the future to formulate a clear perioperative transfusion guideline for these patients.

In this retrospective study, 6 patients had already received a renal transplant prior to nephrectomy. A further 19 (46.3%) patients went on to receive a renal transplant postoperatively. This study did not follow up the outcomes of these patient’s post-transplant and thus information on timing of nephrectomy in relation to transplant cannot be gained from this study. Current research into simultaneous transplantation with nephrectomy has shown comparable outcomes while reducing the number of operations performed on patients [8].