Peritoneal metastases after laparoscopic nephron-sparing surgery for localized Wilms tumor

Minimally invasive and robotic-assisted approaches applied to pediatric surgical oncology

The management of pediatric tumors is complex, with surgery, chemotherapy, and radiotherapy being cornerstones in their treatment. Tumor removal is increasingly performed by a minimally invasive approach, which allows for quicker postoperative recovery and less postoperative pain. The goal of this report is to give an overview of minimally invasive surgical approaches for common pediatric tumors, with a focus on technical considerations and postoperative outcomes.

Technical advances in the surgical management of Wilms tumors in children

Surgery is one of the cornerstones of Wilms tumor treatment. In this article, we present technical advancements that are finding their way into the armamentarium of pediatric cancer surgeons. We discuss the current approaches, challenges, opportunities, and future directions of minimally invasive surgery (laparoscopic and robotics), image-guided surgery, and fluorescence-guided surgery. Furthermore, we discuss the use of intraoperative ultrasonography, as well as the use of new techniques to improve the quality of lymph node sampling.

Abdominal Recurrence after Robotic Nephron-Sparing Surgery for Wilms Tumor in an Adult Patient

A 31-year-old man was referred to an adult urologist for a renal polar mass that measured 7.2 cm in maximum diameter. Robotic assisted complete tumor excision for suspicious renal cell carcinoma was carried out, preserving the rest of the left kidney. Histopathology showed a Wilms tumor (WT) with positive margins. No postoperative therapy was made, and the patient shortly presented an abdominal recurrence. The patient was referred to our pediatric oncology unit; he received preoperative chemotherapy, followed by surgery (completion nephrectomy and removal of neoplastic deposits in the omentum and parietal peritoneum), postoperative chemotherapy, and abdomen radiotherapy. He is well at the 5-year follow-up. Peritoneal dissemination after laparoscopic nephron-sparing surgery (NSS) in a child with a 10-cm WT was previously reported. We suggest open NSS for large WT may be safer than laparoscopic or robotic NSS because carbon dioxide pneumoperitoneum and traumatic handling of tumor may predispose to tumor cell migration. An abdominal WT relapse in adults can be salvaged by multimodal therapy recommended by current pediatric WT guidelines.

Minimally Invasive Techniques in Pediatric Surgical Oncology

Minimally invasive approaches to pediatric cancer surgery are increasingly used, not only for the benefits of smaller incisions, but also for better field visualization and precise dissection. Advances in technology and surgeon experience have facilitated this trend. However, the appropriate indications for its use remain to be determined, and oncologic principles should not be compromised. We discuss the current and potential future uses, and new technologies that are being developed and introduced to assist with and enhance the role of minimally invasive surgery in the management of children with cancer.

A single centre matched pair series comparing minimally invasive and open surgery for the resection of pediatric renal tumours

INTRODUCTION

Minimally invasive nephrectomy (MIN)for the resection of pediatric renal tumors is controversial. We compared patients who underwent laparoscopic MIN according to our unit protocol with matched patients who underwent open surgery (ON).

METHOD

A single centre retrospective analysis of prospectively collected data for MIN. Tumor volume was calculated from pre-operative imaging and volume matched ON patients were identified from the regional tumor database. Demographics, complications, operative time, length of stay, number of nodes resected, status of margins, radiotherapy (RT)requirement, length of follow-up and outcomes were analysed.

RESULTS

Fourteen MINs performed between September 2016 and 11/2019 (M:F 5:9; median age 37 (range 2-73)months) were matched with ON controls (7:7 M:F, median age 42 (1-74)months). Diagnoses in the MIN group were Wilms Tumour (WT)in11 and one each of mesoblastic nephroma (MN), malignant rhabdoid tumour of the kidney (MRTK), nephroblastomatosis and in the ON group were 13 WT and 1 MN. Median operating time for MIN was 180 (125-300)minutes, with 4 conversions and 155 (1-3-480)minutes in ON. There were no intra-operative ruptures. Three tumors in each group had positive margins. A median of 4 (0-6) nodes were removed during MIN and 4 (2-22) during ON. Median length of stay (LoS)was 4 (2-15)days following MIN and 4 (2-9) following MIN. Six ON and 3 MIN patients required radiotherapy. Differences were not significant. Median follow up of 30 (6-44)months for MIN and 73 (34-109)months for ON patients was significantly different. There have been no local recurrences but the child with MRTK died following brain tumor recurrence.

CONCLUSION

MIN for pediatric renal tumors has similar short term outcomes to ON in carefully selected patients.

Minimally invasive surgery for pediatric renal tumors: A systematic review by the APSA Cancer Committee

Minimally invasive nephrectomy is performed routinely for adult renal tumors and for many benign pediatric conditions. Although open radical nephroureterectomy remains the standard of care for Wilms tumor and most pediatric renal malignancies, there are an increasing number of reports of minimally invasive surgery (MIS) for those operations as well. The APSA Cancer Committee performed a systematic review to better understand the risks and benefits of MIS in pediatric patients with renal tumors.

METHODS

The search focused on MIS for renal tumors in children and followed the Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) checklist. The initial database search identified 491 published articles, and after progressive review of abstracts and full-length articles, 19 were included in this review.

RESULTS

There were two direct comparison studies where open surgery and MIS were compared. The remaining studies reported only on minimally invasive nephrectomy. Across all studies, there were a total of 151 patients, 126 of which had Wilms tumor and 10 patients had RCC. 104 patients had MIS, with 47 patients having open surgery. In the two studies in which open surgery and MIS were directly compared, more lymph nodes were harvested during open surgery (median = 2 (MIS) vs 5 (open); mean = 2.47 (MIS) vs 3.8 (open)). Many noncomparison studies reported the harvest of 2 of fewer lymph nodes for Wilms tumor. Several MIS patients were also noted to have intraoperative spill or positive margins. Survival between groups was similar.

CONCLUSIONS

There is a lack of evidence to support MIS for pediatric renal tumors. This review demonstrates that lymph node harvest has been inadequate for MIS pediatric nephrectomy and there appears to be an increased risk for intraoperative spill. Survival data are similar between groups, but follow-up times were inconsistent and patient selection was clearly biased, with only small tumors being selected for MIS.

TYPE OF STUDY

Review article.

LEVEL OF EVIDENCE

III.

3D Model Facilitated Zero-Ischemia Laparoscopic Nephron Sparing Resection in Nephroblastomatosis Following the Addition of Cis-Retinoic Acid

There are limited reports of laparoscopic nephron sparing surgery (LNSS) in children and none where a 3D model facilitated oncological resection. There are also limited reports discussing the use of cis-retinoic acid in bilateral diffuse hyperplastic perilobar nephrogenic rests (DHPLNR). We report the first case of a 3D model facilitated zero-ischemia LNSS in children and the first following treatment with cis-retinoic acid. The patient was a 3-year-old girl with bilateral DHPLNR who had recurrent disease following standard therapy. She had suspicious lesions in the upper pole of the left kidney. Both were completely excised and histologically described as hyperplastic nephrogenic rests.

Minimally invasive surgery to treat embryonal tumors of childhood

Minimally invasive surgery (MIS) to resect primary and metastatic pediatric embryonal tumors offers the potential for reduced postoperative morbidity with smaller wounds, less pain, fewer surgical site infections, decreased blood loss, shorter hospital stays, and less disruption to treatment regimens. However, significant controversy surrounds the question of whether a high-fidelity oncologic resection of childhood embryonal tumors with gross total resection, negative margins, and appropriate lymph node sampling can be achieved through MIS. This review outlines the diverse applications of MIS to treat definitively pediatric embryonal malignancies, including this approach to metastatic deposits. It outlines specific patient populations and presentations that may be particularly amenable to the minimally invasive approach. This work further summarizes the current evidence supporting the efficacy of MIS to accomplish a definitive, oncologic resection without compromising relapse-free or overall survival. Finally, the review offers technical considerations to consider in order to achieve a safe and complete resection.

Comparing oncologic outcomes after minimally invasive and open surgery for pediatric neuroblastoma and Wilms tumor

BACKGROUND

Minimally invasive surgery (MIS) has been widely adopted for common operations in pediatric surgery; however, its role in childhood tumors is limited by concerns about oncologic outcomes. We compared open and MIS approaches for pediatric neuroblastoma and Wilms tumor (WT) using a national database.

METHODS

The National Cancer Data Base from 2010 to 2012 was queried for cases of neuroblastoma and WT in children ≤21 years old. Children were classified as receiving open or MIS surgery for definitive resection, with clinical outcomes compared using a propensity matching methodology (two open:one MIS).

RESULTS

For children with neuroblastoma, 17% (98 of 579) underwent MIS, while only 5% of children with WT (35 of 695) had an MIS approach for tumor resection. After propensity matching, there was no difference between open and MIS surgery for either tumor for 30-day mortality, readmissions, surgical margin status, and 1- and 3-year survival. However, in both tumors, open surgery more often evaluated lymph nodes and had larger lymph node harvest.

CONCLUSION

Our retrospective review suggests that the use of MIS appears to be a safe method of oncologic resection for select children with neuroblastoma and WT. Further research should clarify which children are the optimal candidates for this approach.

The Evolving Role of Minimally Invasive Surgery in Pediatric and Adolescent Urologic Oncology

OBJECTIVE

This review aims at evaluating the current status of minimally invasive surgery at the difficult crossroad between the attractiveness of innovation faced against the solid outcomes offered by the current gold standard, specifically concerning pediatric and adolescent urologic oncology conditions.

METHODS

This is a critical review of the literature and current paradigms on the use of minimally invasive surgery for pediatric and adolescent urologic oncology cancers. Focus is mainly on the use of laparoscopy for the treatment of Wilms' tumors but other neoplasms are also discussed.

RESULTS

We draw parallels with other similar pathologies, respecting critical lessons from international cooperative study groups. We discuss various aspects of the pros and cons of minimally invasive surgery in this patient population and make a case for the development of dedicated pediatric surgeons for urologic cancer.

CONCLUSION

Herein we draft a proposal suggesting a way forward with the adoption of reasonable paradigm shifts founded on carefully conducted studies for the introduction of minimally invasive surgery in the care of pediatric and adolescent urologic cancer.

Videolaparoscopic radical nephrectomy after chemotherapy in the treatment of Wilms' tumor: Long-term results of a pioneer group

INTRODUCTION

A high cure rate for Wilms' tumor has been achieved using a multidisciplinary approach. The natural step forward is to offer the benefits of a minimally invasive technique for surgery, which is an obligatory part of treatment. Nevertheless, some authors resist using videolaparoscopic radical nephrectomy (VRN) because of concerns about reducing the cure index.

METHODS

The present study included children with unilateral Wilms' tumor treated from December 2003 to December 2015 with neoadjuvant chemotherapy followed by VRN. Patients were selected based on the size of their tumors compared with the contralateral kidney, and on their stature.

RESULTS

VRN was performed in 24 patients of age range 10-93 months, with an average of 38.04 ± 23.37 months. The tumoral kidney's largest diameter after chemotherapy averaged 10% of a patient's height. There was no tumor rupture or spillage and no patient presented intra or immediate postoperative complications, except for prolonged ileum in two patients. One patient required intraoperative transfusion because of preoperative anemia. Another developed a late herniation in the umbilical port that required surgical correction. After an average of 6.65 years of follow-up, two patients presented relapse: one with a stage IV disease had relapse in the lung and another with a stage III, involving the liver, had local relapse because of an unwanted delay in the adjuvant treatment.

CONCLUSION

VRN can be considered a feasible alternative to open surgery in selected cases of children with Wilms' tumor. The present experience shows that besides the benefits of minimally invasive procedures and better cosmetic results, there is no evidence of increased tumor rupture or spillage, peritoneal or port site metastasis, and the long-term oncological results are the same as open procedures.

Complications in the surgical management of children with malignant solid tumors

With improvement in the outcomes for children with cancer has come an increasing focus on minimizing the morbidity from therapeutic interventions, including surgical procedures, while continuing to have a high likelihood of cure. Thus, an appreciation for the potential complications of surgery, both acute and long term, is critical when considering the risks and benefits of any procedure performed on a child with cancer. Although not meant to be an exhaustive review, here we discuss the most common and significant surgical complications that may occur when performing diagnostic, therapeutic, or supportive procedures in children with the most common malignant solid tumors.

Abdominal tumors in children: Comparison between minimally invasive surgery and traditional open surgery

The use of minimally invasive surgery (MIS) in pediatric patients has been steadily increasing in recent years. However, its use for diagnosing and treating abdominal tumors in children is still limited compared with adults, especially when malignancy is a matter of debate. Here, we describe the experience at our center with pediatric abdominal tumors to show the safety and feasibility of MIS.Based on a retrospective review of patient records, we selected for study those pediatric patients who had undergone diagnostic exploration or curative resection for abdominal tumors at a single center from January 2010 through August 2015.Diagnostic exploration for abdominal tumors was performed in 32 cases and curative resection in 173 cases (205 operations). MIS was performed in 11 cases of diagnostic exploration (34.4%) and 38 cases of curative resection (21.9%). The mean age of the children who underwent MIS was 6.09 ± 5.2 years. With regard to diagnostic exploration, patient characteristics and surgical outcomes were found to be similar for MIS and open surgery. With regard to curative resection, however, the mean age was significantly lower among the patients who underwent open surgery (4.21 ± 4.20 vs 6.02 ± 4.99 for MIS, P = 0.047), and the proportion of malignancies was significantly higher (80% vs 39.4% for MIS, P < 0.001). MIS compared favorably with open surgery with respect to the rate of recurrence (6.7% vs 35.1%, P = 0.035), the rate of intraoperative transfusions (34.2% vs 58.5%, P = 0.01), the median amount of blood transfused (14 vs 22 mL/kg, P = 0.001), and the mean number of hospital days (4.66 ± 2.36 vs 7.21 ± 5.09, P < 0.001). Complication rates did not differ significantly between the MIS and open surgery groups. The operation was converted to open surgery in 3 cases (27.2%) of diagnostic MIS and in 5 cases (13.1%) of curative MIS.MIS was found to be both feasible and effective for the diagnosis and curative treatment of pediatric abdominal tumors. However, to determine the surgical role and guidelines for MIS for each specific tumor, a multicenter prospective study with a long-term follow-up is warranted.

"Zero-Ischemia" Laparoscopic-assisted Partial Nephrectomy for the Management of Selected Children With Wilms Tumor Following Neoadjuvant Chemotherapy

OBJECTIVE

To describe the experience and technique of zero-ischemia laparoscopic-assisted partial nephrectomy at The Hospital for Sick Children, as an alternative to the traditional open approach for nephron-sparing surgery (NSS) in selected children with Wilms tumor (WT).

MATERIALS AND METHODS

Patients with diagnosis of WT treated with neoadjuvant chemotherapy and who underwent laparoscopic-assisted NSS at the Hospital for Sick Children from 2012 to 2016 were identified and their charts were reviewed retrospectively. Patients underwent laparoscopic exploration, lymph node sampling, kidney mobilization, vascular control, and adrenal sparing. This was followed by open NSS through a small flank incision; no clamping of the hilum or major renal branches was performed.

RESULTS

Six patients were identified; all patients underwent successful resection. One patient required radical nephrectomy due to inability to safely define negative margins. Tumors ranged in size from 0.9 to 5.6 cm in diameter. Mean operating time was 293 ± 50.2 minutes, with an average duration of pneumoperitoneum of 216 ± 27 minutes. Intraoperative blood loss was negligible. No tumor spillages occurred. Postoperative pathology revealed negative margins in all resected specimens. One case of urine leak occurred postoperatively, which resolved spontaneously. Renal function was preserved in all children. At a mean follow up of 11.5 months, all patients have been recurrence free.

CONCLUSION

The herein presented strategy allows for safe nephron-sparing resection of selected WT with acceptable morbidity, good short-term disease-free survival, and potentially better cosmesis and recovery than traditional open surgery. This preliminary experience suggests that minimally invasive options for NSS in children merit further evaluation.

Minimally invasive surgery in management of renal tumours in children

Minimally invasive surgery (MIS) in the management of malignant and benign renal tumours in children is gradually becoming more common. Experience is limited and restricted to case reports, retrospective chart reviews and a few cohort studies. There are currently no randomized controlled trials or controlled clinical trials comparing the laparoscopic and open surgical approach for the management of renal tumours in children. MIS may offer the same oncologic outcome in malignant renal tumours whilst providing the advantages associated with MIS in correctly selected cases. The technique for tumour resection has been shown to be feasible in regards to the recommended oncologic principles, although lymph node sampling can be inadequate in some cases. Preliminary reports do not show an increased risk of tumour rupture or inferior oncologic outcomes after MIS. However, the sample size remains small and duration of follow-up inadequate to draw any firm conclusions. Implementation of MIS is lacking in the protocols of the major study groups, and standardized recommendations for the indications and contra-indications remain undefined. The objective of this article is to present a review of the literature on the role of MIS in the management of renal tumours in children, with the main focus on Wilms' tumour (WT). Further studies on MIS in renal tumours are required to evaluate the incidence of oncological complications such as complete tumour resection and intra-operative tumour spillage. A long-term follow-up of patients managed by MIS is essential to compare recurrence rates and overall survival rates.

[Surgical concepts in the treatment of Wilms tumor: An update]

BACKGROUND

Treatment results of Wilms tumors have been impressively improved over the past 50 years resulting in a stage-independent overall survival of greater than 90%. However, unsatisfying treatment results still remain in children with high-risk tumors and tumor relapses.

MATERIALS AND METHODS

This review highlights the current concepts of Wilms tumor surgery as a cornerstone of the treatment strategy for this malignancy. A selective literature review focusing on the past 5 years served as the basis for this article.

RESULTS

Nephron-sparing surgery is associated with an analogue outcome compared to tumor nephrectomy in unilateral Wilms tumors. The surgical panel of the International Society of Pediatric Oncology (SIOP) group has recently introduced a novel nomenclature for organ-preserving resection procedures in order to facilitate a prospective comparison of data. The minimally invasive approach represents an alternative technique with adequate outcome. In bilateral disease, nephron-sparing procedures are gold standard. Complete resection of lung and liver metastases has a significant impact on patients' survival.

CONCLUSIONS

Surgical guidelines for nephron-sparing surgery and minimally invasive tumor nephrectomy need to be established and implemented within newly formulated treatment protocols of the different national and international treatment trials. Risk stratification of patients needs to be more individualized with the aim of reducing late effects while at least maintaining the same survival rates. The unsatisfying treatment results of tumor relapses-associated with low patient numbers within the different trials-emphasize the need for international collaboration.

Laparoscopic Nephron-sparing Surgery for Metanephric Adenoma in Children: A Report of 2 Cases

Metanephric adenoma (MA) is an epithelial benign tumor of the kidney and very rare in children. Here we present 2 cases of MA treated by laparoscopic nephron-sparing surgery in children. To the best of our knowledge, we report the first cases of laparoscopic nephron-sparing surgery for MA in children.

Current surgical standards of care in Wilms tumor

BACKGROUND

Wilms tumor (WT) is the second most common abdominal tumor in children.

METHODS

This chapter discusses surgical considerations for the management of unilateral and bilateral WT.

RESULTS

Currently, survival exceeds 90%, owing to multicenter studies under the auspices of the Children's Oncology Group and Société Internationale d'Oncologie Pédiatrique. Surgical excision remains the mainstay of oncologic control and is also crucial for proper staging of disease in order to direct adjuvant therapy and limit treatment-related morbidity.

CONCLUSIONS

Careful attention must be paid to proper disease staging, upfront and adjuvant therapy, and surgical technique in order to optimize oncologic outcomes while minimizing short- and long-term morbidity.

Prechemotherapy robotic-assisted laparoscopic radical nephrectomy for an adolescent with Wilms tumor

Although Wilms tumor (WT) is the most common pediatric renal tumor, adolescent and adult WT is rare. Nevertheless, adolescent renal tumors as a group are sufficiently uncommon that WT must be included in the differential diagnosis for such patients, and in doing so affects the oncologic considerations of the surgery. Herein, we describe a 14-year-old female presenting with a 1-month history of right flank pain. Subsequent work-up revealed a localized, centrally located, enhancing right renal mass. The patient underwent robotic-assisted laparoscopic radical nephrectomy and pathology demonstrated stage II, favorable histology WT. Herein, we will discuss the pertinent details regarding adolescents with renal tumors and the risks and benefits of using a minimally invasive surgical approach.

NEPHRON-SPARING SURGERY FOR BILATERAL WILMS TUMOR

Synchronous bilateral disease occurs in approximately 5 % of children with Wilms tumor (WT), and is independently associated with an increased risk of renal insufficiency. Nephron-sparing surgery (NSS) allows preservation of renal mass and improved renal function. Published oncologic and functional outcomes with NSS to date are generally good, likely reflecting proper patient selection and excellent surgical technique during tumor excision, as well as appropriate use of upfront and adjuvant therapies. Here we highlight important issues regarding the use of NSS in children with bilateral Wilms tumor (BWT).

The role of minimally invasive surgery in pediatric solid tumors

During recent years, minimally invasive surgery (MIS) has become the standard approach for various operations in infants and children. MIS in pediatric thoracic and abdominal tumors is a controversial approach in the surgical management of childhood cancer. Meanwhile, more and more oncological biopsies and resections are being performed laparoscopically or thoracoscopically. Despite its increasing role in pediatric tumor surgery, the different national and international multicenter trial groups have not yet implemented MIS within guidelines and recommendations in most of the current treatment protocols. An increasing number of retrospective reports describes a potential role of MIS in the management of different pediatric oncological entities. Over the time, there has been a diverse development of this approach with regard to the different neoplasms. Nevertheless, there is a lack of prospective randomized trails assessing MIS. This still represents a requirement for evidence-based medicine and judging the advantages and disadvantages of this approach. The purpose of this state-of-the-art article is to review the current literature to describe the application of MIS in pediatric solid tumors.

Minimally invasive nephrectomy for Wilms tumors in children - data from SIOP 2001

PURPOSE

To analyse the surgical and oncological outcome of minimally invasive surgery (MIS) for tumor nephrectomy in Wilms tumor (WT) patients.

METHODS

WT patients from the SIOP 2001 trial, undergoing MIS for tumor nephrectomy were analyzed with regard to demographic characterization, surgical specifications, complications, and outcome.

RESULTS

There were 24 children matching the inclusion criteria. Median age at operation was 40.35 months (14.3-65.4). All patients received preoperative chemotherapy. Median tumor volume was 177.5 ml at diagnosis (46.5-958) and 73.0 ml at surgery (3.8-776). There was one surgical complication (splenic injury), no intraoperative tumor rupture occurred. Abdominal stage was I in 14, II in 7, and III in 3 patients. Adequate lymph node sampling was performed in only 2 patients. One local relapse occurred. Event-free survival was 23/24, overall survival was 24/24, median follow up was 47 months (2-114).

CONCLUSIONS

We present the largest series so far of minimally invasive nephrectomies for nephroblastoma based on a multinational trial. Treatment results were comparable to those of open surgery; however, experience of operating surgeons was generally high. Discipline of lymph node sampling was inadequate. Based on this analysis a prospective study on MIS in nephroblastoma is planned by the SIOP Renal Tumor Study Group.

Innovations in the management of Wilms' tumor

Advances in the management of Wilms' tumor have been dramatic over the past half century, not in small part due to the institution of multimodal therapy and the formation of collaborative study groups. While different opinions exist in the management of Wilms' tumors depending on where one lives and practices, survival rates have surpassed 90% across the board in Western societies. With more children surviving into adulthood, the concerns about morbidity have reached the forefront and now represent as much a consideration as oncologic outcomes these days. Innovations in treatment are on the horizon in the form of potential tumor markers, molecular biological means of testing for chemotherapeutic responsiveness, and advances in the delivery of chemotherapy for recurrent or recalcitrant tumors. Other technological innovations are being applied to childhood renal tumors, such as minimally invasive and nephron-sparing approaches. Risk stratification also allows for children to forego potentially unnecessary treatments and their associated morbidities. Wilms' tumor stands as a great example of the gains that can be made through protocol-driven therapy with strenuous outcomes analyses. These gains continue to spark interest in minimization of morbidity, while avoiding any compromise in oncologic efficacy. While excitement and innovation are important in the advancement of treatment delivery, we must continue to temper this enthusiasm and carefully evaluate options in order to continue to provide the highest standard of care in the management of this now highly curable disease.

Minimally invasive surgery in the management of abdominal tumors in children

The application of minimally invasive surgical techniques to pediatric abdominal tumors is a controversial application towards the surgical management of childhood cancer. Although general pediatric surgeons practice minimally invasive surgery techniques in a vast array of abdominal cases, its role in pediatric oncology is still developing, with no consensus in North America about its use for pediatric solid abdominal tumors. The purposes of this article are to review the current literature about the use of minimally invasive surgery in pediatric abdominal oncology and to examine established indications, procedures and technologic advances.

Comparison between laparoscopic and open radical nephrectomy for the treatment of primary renal tumors in children: single-center experience over a 5-year period

OBJECTIVES

To compare the outcomes of laparoscopic nephrectomy (LN) with open radical nephrectomy (ORN) in the management of consecutive pediatric neoplasms.

PATIENTS AND METHODS

Retrospective cohort study of consecutive children treated for primary renal tumors between 2006 and 2011, segregated based on surgical modality (LN/ORN). Pre-, intra- and postoperative data and outcomes were collected.

RESULTS

Demographics from the 45 patients (13 LN, 32 ORN) were similar, and tumors in the LN group were smaller [6.59 ± 1.8 cm vs. 10.99 ± 2.99 cm ORN (p < 0.05)]. Six patients had preoperative chemotherapy (two LN, four ORN). No tumor ruptures occurred with either technique. Wilms tumor (seven LN, 24 ORN) was the most common diagnosis, followed by renal cell carcinoma (four LN, four ORN). Procedure length was similar between groups (282 ± 79 LN, 263 ± 81 min ORN). Mean length of stay was significantly shorter for LN (2.9 vs. 5.9 days; p = 0.002). Postoperative narcotic requirements and use of nasogastric tube were higher in the ORN group. After a median follow-up of 18 (LN) and 33 months (ORN), 1 and 4 recurrences occurred, respectively.

CONCLUSIONS

LN is an attractive alternative to open surgery in carefully selected cases of pediatric renal tumors. Procedure length and incidence of intra-operative rupture were not increased, while post-operative recovery and hospital stay were shorter for LN. Longer follow-up is mandatory to confirm comparable oncological outcomes to ORN.

Laparoscopic treatment of renal cancer in children: a multicentric study and review of oncologic and surgical complications

OBJECTIVE

The aim was to report a multicentric study with a longer follow-up to evaluate the laparoscopic radical nephrectomy in children with renal cancer.

MATERIAL AND METHODS

This was a retrospective multicentric study, from October 2005 to January 2012, of children who underwent a laparoscopic radical nephrectomy for small renal malignant tumors.

RESULTS

Seventeen children were included in this study. Sixteen underwent chemotherapy before surgery according the SIOP (Société Internationale d'Oncologie Pédiatrique) protocol and one was treated by surgery only for a carcinoma. All except one could be treated by laparoscopy; the biggest tumoral size was 8 cm. The median hospital stay was 3 days (2-10). The pathologic examination showed 15 Wilms' tumors, one clear cell sarcoma and one TFE3 renal cell carcinoma. With a median follow-up of 42 months (range 12 and 77 months) after laparoscopic radical nephrectomy, 15 children had no oncological complications (port site or local recurrence, pulmonary metastasis) and one had a local recurrence without intraoperative tumoral rupture. The child with TFE3 renal cell carcinoma died 4 years after surgery from brain and lung metastases without local recurrence. No small bowel obstruction occurred.

CONCLUSIONS

Radical nephrectomy in children for Wilms' tumor or other renal cancer can be safely performed laparoscopically and our indications can be summarized, for trained laparoscopic surgeons, by small tumors under about 8 cm diameter, especially without crossing the lateral edge of the vertebra on the CT scan at the time of surgery.

Oncology: the role of partial nephrectomy in Wilms tumor

Wilms tumor represents the most common pediatric renal malignancy and the fourth most common childhood cancer overall. Overall survival from Wilms tumor has increased to over 90 % secondary to multidisciplinary therapy and multi-institutional cooperative group trials. Recent therapeutic focus has shifted to reduction in treatment morbidity and renal preservation while maintaining the high survival rates. Partial nephrectomy is an integral component of the multimodal treatment protocols for Wilms tumor patients with bilateral disease, solitary kidney, or predisposing syndromes. Recent consideration has been given to utilization of nephron sparing surgery (NSS) in carefully selected patients with nonsyndromic unilateral Wilms tumor. While long-term, prospective data in this subgroup of patients is not yet available, case series demonstrate comparable oncologic outcomes after partial versus radical nephrectomy. The relative rarity of Wilms tumor, especially those amenable to upfront partial nephrectomy, presents a challenge to conducting controlled trials.

Minimally invasive nephron-sparing surgery for unilateral Wilms tumor

Minimally invasive surgery (MIS) for nephrectomy has been described since the early 1990s. More recently, MIS has been used for nephron-sparing surgery (NSS) when treating benign conditions. However, reports of NSS using MIS for malignant conditions are sparse. In this report, we describe our retroperitoneal laparoscopic approach for NSS for a localized Wilms tumor.

Wilms' tumor- roadmaps of management

The management of Wilms' tumor emerging of the outstanding clinical trials undertaken in the developed world in the last four decades has led to excellent longterm outcomes. The scenario in developing country like India is different; late presentation with massive tumors and advanced stage, lacunae in staging, nonavailability of pediatric medical oncologists and poor follow-ups are common. A comprehensive summary of available therapeutic modalities is provided here along with clear roadmaps of management of Wilms' tumor as per Société Internationale d'Oncologie Pédiatrique (SIOP) and National Wilms' Tumor Study Group/Children's Oncology Group (NWTSG/COG) protocols in simple tabulated form.

Wilms tumor

Significant improvement has been made in the treatment of children with Wilms tumor. New protocols are in place designed to maintain a high rate of cure for these patients while minimizing toxicity, based on refinement of the risk-stratification system.