Transperitoneal and retroperitoneal laparoscopic heminephrectomy--what approach for which patient?

Perioperative morbidity of paediatric laparoscopic nephrectomy by transperitoneal and retroperitoneal approaches- any difference?

AIM

Minimal invasive approaches for paediatric nephrectomy include transperitoneal (TP) and retroperitoneal (RP); both having advantages and disadvantages. We aimed to ascertain if there was any difference in perioperative morbidities between these two approaches.

METHODS

We performed a retrospective review of laparoscopic TP and RP nephrectomies performed in our institution over 10 years from May 2009 till May 2019. Outcome measures included intraoperative complications, prolonged requirement of opioid analgesics (more than 24 h), hospital stay, incidence of wound infection and urinary tract infections. Data were analysed using Fisher's exact test and Mann Whitney test.

RESULTS

A total of 152 nephrectomies were performed in 139 patients; 81 were TP and 71 were RP. Age ranged from 8 months to 16 years. Median hospital stay was 2 days in both groups. There were no intraoperative complications. Outcome measures were sub-categorised as follows. Requirement of opioid analgesia for more than 24 h was documented in 2 patients in each group, leading to longer hospital stay of 3 days. A febrile urinary tract infection requiring antibiotics was detected in 4; 1 in TP and 3 in RP. Wound infection requiring antibiotics occurred in 1 patient (in RP group). No statistically significant difference was found between the two groups in any of the subcategories.

CONCLUSION

TP and RP nephrectomy have similar perioperative morbidity. The decision to utilise either approach should be dependent on the surgeon's skills and experience and appropriately tailored to individual patient needs.

Retroperitoneoscopic approach for partial nephrectomy in children with duplex kidney: A case report

BACKGROUND

Renal duplication is a common deformity of the urinary system, with an incidence of approximately 1/125 in children. Symptomatic patients with hydronephrosis, vesicoureteral reflux, or incontinence may require surgical interventions. Laparoscopy and retroperitoneoscopy are the two main accesses for partial nephrectomy.

CASE SUMMARY

A 9-year-old child was admitted to the hospital for hydronephrosis of the left kidney. Ultrasonography showed that the left kidney was larger, approximately 12.6 cm × 6.3 cm × 5.5 cm in size, with visible separation of the pelvis and an obviously separated lower portion. The upper segment of the left ureter was dilated (approximately 2.6 cm in width), and no significant dilation was observed in the middle and upper segments. The right kidney and ureter were normal. Primary diagnosis was left renal duplication malformation and hydronephrosis. Retroperitoneal laparoscopic nephrectomy and ureterectomy were performed. Intraoperative exploration revealed a dilated pelvis and thin renal parenchyma at the lower pole of the left kidney. The upper left kidney was smaller than normal, and the pelvis and ureter were larger than normal. The renal artery was blocked for 40 min. A hemolock was used to clamp down the kidney ureter, and a drainage tube was retained in the retroperitoneal cavity. The operation was uneventful, and the estimated amount of blood loss was 100 mL. Total abdominal drainage amount was 116 mL. The drainage tube was removed on postoperative day (POD) 3 and the patient was discharged on POD6. The pathological diagnosis confirmed the atrophy of the renal parenchyma, the dilation of the renal pelvis, hydronephrosis, and ureteral cystic dilation.

CONCLUSION

The retroperitoneoscopic approach for partial nephrectomy is feasible and effective in selective pediatric patients with a duplex kidney.

Predictors of complications following retroperitoneoscopic total and partial nephrectomy

INTRODUCTION

Recent reports in the literature suggest an increased risk of complications with retroperitoneal as opposed to transperitoneal approach to partial nephrectomy (PN) and total nephrectomy (TN). We are a large unit performing predominantly retroperitoneoscopic PN and TN. We aim to review our outcomes and perform analysis to elucidate the predictors of complications following the retroperitoneal approach for extirpative kidney surgery.

METHODS

We performed a single center retrospective review of children undergoing MIMS TN and PN between 2005 and 2015. Variables were tested for association with outcomes using Chi² and Spearman's Rho correlation.

RESULTS

We performed 173 MIMS nephrectomies, 119 total and 54 partial. Median age and weight were 5 years (6 months to 18 years) and 24.9 kg (7.7 to 85 kg) and operative time 147 min. There were 4 conversions and 17 postoperative complications. 19.6% children required further surgery, including 8 completion stumpectomies. Retroperitoneal approach did not have increased risk compared to transperitoneal for need of further surgery. Partial nephrectomy was not associated with higher rate of intraoperative complication or LOS. Predictors of intraoperative complication were vessel closure technique. Associations with need for further surgery were: ESRF, contralateral disease, bladder dysfunction, presence of PD catheter, and need for concomitant procedure.

CONCLUSION

Our conversion rate (1.9%) and need for further surgery (13.1%) following the retroperitoneal approach to the kidney are favorable to the literature. Need for reoperation is often associated with the underlying diagnosis and the natural sequelae of the disease process.

LEVEL OF EVIDENCE

IV.

Laparoscopic Heminephrectomy for Duplex Kidney in Children-The Learning Curve

Objectives: Outcomes evolution during the learning curve of laparoscopic transperitoneal heminephrectomy in children with a duplex kidney. Materials and Methods: The data of 33 children, operated on between 2008 and 2017, with complicated duplex kidney, were subjected to a retrospective analysis. All patients were operated on by transperitoneal access using the laparoscopic technique. Patients were divided into two groups (1: subsequent operation 1-16, and 2: operations 17-33) to evaluate the learning curve. Results: There was no need for conversion. Total complications occurred in seven patients in Group 1 and 2 patients of Group 2 (p < 0.05). Two patients (6%) (both upper pole heminephrectomies) required reoperation to remove the ureter stump because of recurrent UTIs due to undiagnosed VUR to the stump (1 from each of Groups 1 and 2). Prolonged urine leakage (over 4 days) was observed in four patients (12%; all from group 1); in three patients, conservative treatment was successful, while the placement of a DJ catheter was needed in the fourth. A significant decrease of kidney function (>6%) in scintigraphy was observed in two of the 15 patients after the surgery. The time of surgery decreased from 140 (range 85-185) min in Group 1 to 125 (range 100-150) min in Group 2 (p < 0.05). Conclusions: Laparoscopic heminephrectomy is connected to the learning curve. Most complications occurred in the first 16 operations. With increasing experience, the time of operation decreased. In patients with reflux to the upper pole, referred for upper pole heminephrectomy, it is necessary to consider the removal of the ureter to the level of the vesicoureteral junction.

Retroperitoneoscopic partial nephrectomy in children: a multicentric international comparative study between lateral versus prone approach

BACKGROUND

Very limited informations are currently available about the best approach to perform retroperitoneoscopic surgery. This multicentric international study aimed to compare the outcome of lateral versus prone approach for retroperitoneoscopic partial nephrectomy (RPN) in children.

METHODS

The records of 164 patients underwent RPN in 7 international centers of pediatric surgery over the last 5 years were retrospectively reviewed. Sixty-one patients (42 girls and 19 boys, average age 3.8 years) were operated using lateral approach (G1), whereas 103 patients (66 girls and 37 boys, average age 3.0 years) underwent prone RPN (G2). The two groups were compared in regard to operative time, postoperative outcome, postoperative complications, and re-operations.

RESULTS

The average operative time was significantly shorter in G2 (99 min) compared to G1 (160 min) (p = 0.001). Only 2 lateral RPN required conversion to open surgery. There was no significant difference between the two groups as for intraoperative complications (G1:2/61, 3.3%; G2:6/103, 5.8%; p = 0.48), postoperative complications (G1:9/61, 14.7%; G2:17/103, 16.5%; p = 0.80), and re-operations (G1:2/61, 3.3%; G2:4/103, 3.8%; p = 0.85). Regarding postoperative complications, the incidence of symptomatic residual distal ureteric stumps (RDUS) was significantly higher in G2 (7/103, 6.8%) compared to G1 (1/61, 1.6%) (p = 0.001). Most re-operations (4/6, 66.6%) were performed to remove a RDUS .

CONCLUSIONS

Both lateral and prone approach are feasible and reasonably safe to perform RPN in children but the superiority of one approach over another is not still confirmed. Although prone technique resulted faster compared to lateral approach, the choice of the technique remains dependent on the surgeon's personal preference and experience. Our results would suggest that the lateral approach should be preferred to the prone technique when a longer ureterectomy is required, for example in cases of vesico-ureteral reflux into the affected kidney moiety, in order to avoid to leave a long ureteric stump that could become symptomatic and require a re-intervention.

Transperitoneal laparoscopic heminephroureterectomy in pediatric population: A single-centre experience using a sealing device

INTRODUCTION

We sought to report the outcomes of transperitoneal laparoscopic heminephroureterectomy (LHNU) in pediatric population and to describe the technical details of this minimally invasive surgery.

METHODS

Seventeen pediatric patients (18 renal units), who had consecutive transperitoneal LHNU in our department between January 2012 and July 2017 were included in the study. In all patients, diagnostic cystoscopy and retrograde pyelography were carried out immediately before the operation. A catheter was inserted in the unaffected ureter and fixed. LHNU with a transperitoneal approach was carried out in all patients with the aid of LigaSure^®. After removal of the specimen, the intervention was finalized with the insertion of a drain. All intraoperative and postoperative data of the patients were recorded prospectively.

RESULTS

The average age of the patients was 55.9±35.8 months (range 8-121). The average duration of the operations was 121.7±24.0 minutes (range 100-200). The average hospitalization time was 1.6±0.4 days (range 1-2). No intraoperative complication occurred in our patients. The average followup period was 29.1±13.4 months (range 4-48). During the followup period, no complications were observed except one patient who had pyelonephritis within the first month of surgery.

CONCLUSIONS

Transperitoneal LHNU is a minimally invasive method that can be used safely in pediatric patients. Using a standardized technique during the procedure is critical to increase the success and decrease the complication rates.

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.

Partial nephrectomy for small children: Robot-assisted versus open surgery

OBJECTIVES

To compare the outcomes of robot-assisted heminephrectomy for duplex kidney in children with those of open heminephrectomy.

METHODS

The present retrospective multicentric analysis reviewed the records of robot-assisted versus open heminephrectomy carried out for duplex kidney in children from 2007 to 2014. Demographic data, weight, surgical time, hospital stay, complications and outcome were recorded. Follow up was based on a clinical review, renal sonography and dimercaptosuccinic acid renal scintigraphy.

RESULTS

A total of 15 patients underwent robot-assisted heminephrectomy, and 13 patients underwent retroperitoneal heminephrectomy by open approach. All patients weighed <15 kg. The mean age at the time of surgery was 20.2 months (range 7-39 months) in the robotic group, and 18.4 months (range 6-41 months) in the open group. The mean hospital stay was statistically longer for the open surgery group (6.3 days, range 5-8 days vs 3.4 days, range 1-7 days; P < 0.001). Regarding postoperative pain control, total morphine equivalent intake was statistically greater for the open group (0.52 mg/kg/day vs 1.08 mg/kg/day; P < 0.001). No patient lost the remaining healthy moiety. There was no significant difference in terms of operating time, complication rate or renal outcomes.

CONCLUSIONS

Robot-assisted heminephrectomy in small children seems to offer comparable renal outcomes with those of its standard open surgery counterpart. Specific technical adjustments are necessary, which typically increase the set-up time.

Outcome of laparoscopic upper pole heminephroureterectomy in children: A two-centre experience

OBJECTIVE

To report our multicentre experience and outcomes with laparoscopic transperitoneal and retroperitoneal upper pole heminephroureterectomy (HNU) in children with renal duplex systems and impaired upper pole.

PATIENTS AND METHODS

Laparoscopic HNU was performed in 22 children (15 girls, seven boys) with a mean age of 5.9 years. A retroperitoneal approach was used in 17 patients and a transperitoneal approach in the remaining five, between 2005 and 2010. Urinary tract infection was the initial presenting symptom in all children except for one with urinary retention caused by a large ureterocele. Voiding cystourethrography and renal scintigraphy revealed dual collecting systems on the right side in 11 and on the left in 11 cases. The upper pole collecting system was non-functioning in all cases. Postoperative ultrasonography was done at 1 and 3 months, with renal scintigraphy at 3 months, to check the remaining function of the lower moiety.

RESULTS

Overall, the mean operation time was 152 min (144 min for retroperitoneal and 160 min for transperitoneal). Blood loss was 10-50 mL and there were no intraoperative complications. The mean (SD) hospitalisation and postoperative follow-up were 3.5 (1.25) days and 22 (9.83) months, respectively. Postoperative recovery was uneventful and at the 3-month follow-up renal scintigraphy revealed no parenchymal loss of the remaining renal moiety.

CONCLUSION

Laparoscopic HNU in children can be performed via transperitoneal or retroperitoneal approach, both with low morbidity and with the typical benefits of laparoscopic surgery.

Retroperitoneal and laparoscopic heminephrectomy in duplex kidney in infants and children

BACKGROUND

Two main techniques are adopted to perform partial nephrectomy in children: laparoscopy and retroperitoneoscopy. The aim of this paper is to review the larger multicentric experience recently published by our group to review indications, techniques and results of both approaches.

METHODS

Data of 102 patients underwent partial nephrectomy in a 5-year period using minimally invasive surgery (MIS) procedures were analyzed. Fifty-two children underwent laparoscopic partial nephrectomy (LPN), and 50 children underwent retroperitoneoscopic partial nephrectomy (RPN). Median age at surgery was 4.2 years. Statistical analysis was performed using χ² test and Student's t-test.

RESULTS

The overall complications rate was significantly higher after RPN (15/50, 30%) than after LPN (10/52, 19%) (χ² =0.05). In LPN group, complications [4 urinomas, 2 symptomatic refluxing distal ureteral stump (RDUS) and 4 urinary leakages] were conservatively managed. In RPN group, complications (6 urinomas, 8 RDUS, 1 opening of remaining calyxes) required a re-operation in 2 patients. In both groups no conversion to open surgery was reported. Operative time (LPN: 166.2 min vs. RPN: 255 min; P<0.001) and hospitalization (LPN: 3.5 days vs. RPN: 4.1 days; P<0.001) were significantly shorter in LPN group. No postoperative loss of renal function was reported in both groups.

CONCLUSIONS

MIS now represents the gold standard technique to perform partial nephrectomy in children with duplex kidney. Our results demonstrate that RPN remains a technically demanding procedure with a significantly higher complications and re-operation rate compared to LPN. In addition, length of surgery and hospitalization were significantly shorter after LPN compared to RPN. LPN seems to be a faster, safer and technically easier procedure to perform in children compared to RPN due to a larger operative space and the possibility to perform a complete ureterectomy in refluxing systems.

Retroperitoneal Versus Transperitoneal Laparoscopic Partial Nephrectomy: A Systematic Review and Meta-analysis

OBJECTIVE

To review published literatures comparing the safety and effectiveness of retroperitoneal laparoscopic partial nephrectomy (RLPN) with transperitoneal laparoscopic partial nephrectomy (TLPN) and provide reference for clinical work.

METHODS

The search strategy was performed to identify relevant papers from the Cochrane Central Register of Controlled Trials, EMBASE, MEDLINE, Google Scholar, China Hospital Knowledge Database, Wangfang Chinese Periodical Database, and VIP Chinese Periodical Database. All papers comparing RLPN with TLPN were included from 2000 to 2015. Two to three reviewers independently screened, evaluated, and extracted the included papers. A Meta-analysis was executed by using Review Manager 5.3 software. The interesting outcomes were tumor size, operating time, estimated blood loss, warm ischaemia time, length of hospital stay, positive margin rate, open conversion rate, overall complication rate, and recurrence rate.

RESULTS

The literature search obtained 378 papers, then 10 of them were ultimately met the inclusion criteria and included in the systematic review. Finally, 6 of the 10 papers were included in the Meta-analysis. RLPN had significantly less operating time [P = 0.01, mean difference (MD)=-33.68, 95% confidence interval (CI) within (-60.35, -7.01)] and shorter length of hospital stay [P < 0.0001, MD=-1.47, 95% CI within (-2.18, -0.76)] than TLPN. Significant differences were not found between RLPN and TLPN in other outcomes.

CONCLUSIONS

RLPN may be equally safe and be faster than TLPN. Each center can choose a modality according to your own operating habits and experience.

Is renal scintigraphy necessary after heminephrectomy in children?

INTRODUCTION

Heminephrectomy remains an excellent option for a poorly functioning moiety in a duplicated collecting system. A primary concern during heminephrectomy is the potential for a significant functional loss in the remaining ipsilateral moiety. As the gold standard for the assessment of differential renal function, renal scintigraphy is often used in the postoperative evaluation of children undergoing heminephrectomy. However, this imaging modality is costly, invasive, and associated with exposure to radiation. Doppler renal ultrasound (RUS) avoids these concerns and is able to evaluate for structural and functional abnormalities.

OBJECTIVE

The present study sought to compare Doppler RUS to renal scintigraphy in determining the viability of the remaining ipsilateral moiety in children who underwent heminephrectomy for a poorly functioning moiety in a duplicated collecting system.

MATERIALS AND METHODS

The institutional database of children who underwent open heminephrectomy for a poorly functioning moiety in a duplicated collecting system between 2006 and 2013 was reviewed. Only children who underwent both a postoperative Doppler RUS and renal scan were included. A blinded pediatric radiologist independently reviewed all Doppler RUS. Vascular flow on Doppler RUS was correlated with the preservation of renal function in the remaining ipsilateral moiety on renal scintigraphy.

RESULTS

A total of 29 children were identified for inclusion. Demographic and operative data are provided in Table. The average pre-operative and postoperative differential renal function in the ipsilateral kidney was 41.6% and 38% on renal scintigraphy, respectively, for an average decrease of 3.6% (-18% to +12%). Doppler RUS demonstrated the presence of vascular flow to the remaining ipsilateral moieties of all children after heminephrectomy. Renal scintigraphy confirmed the viability of these moieties in all children.

DISCUSSION

The first study comparing Doppler RUS to renal scintigraphy was performed to determine the viability of the remaining ipsilateral moiety after heminephrectomy. While no cases of complete functional loss were observed, an average decrease of 3.6% in the ipsilateral renal function favorably compared with other series of children undergoing open heminephrectomy. The limitations of the study included its retrospective design at a single institution. The interpretation of Doppler RUS by an individual pediatric radiologist may also have lead to interobserver variability and impacted the reproducibility of the study, while the absence of any cases of complete functional loss may have impacted its generalizability.

CONCLUSIONS

Doppler RUS is an accurate imaging modality for determining the viability of the remaining ipsilateral moiety after heminephrectomy and may obviate the need for renal scintigraphy.

A comparison between laparoscopic and retroperitoneoscopic approach for partial nephrectomy in children with duplex kidney: a multicentric survey

PURPOSE

To compare the outcome of laparoscopic and retroperitoneoscopic approach for partial nephrectomy in infants and children with duplex kidneys.

METHODS

Data of 102 patients underwent partial nephrectomy in a 5-year period using MIS procedures were analyzed. Fifty-two children underwent laparoscopic partial nephrectomy (LPN), and 50 children underwent retroperitoneoscopic partial nephrectomy (RPN). Median age at surgery was 4.2 years. Statistical analysis was performed using χ (2) test and Student's t test.

RESULTS

The overall complications rate was significantly higher after RPN (15/50, 30 %) than after LPN (10/52, 19 %) [χ (2) = 0.05]. In LPN group, complications [4 urinomas, 2 symptomatic refluxing distal ureteral stumps (RDUS) and 4 urinary leakages] were conservatively managed. In RPN group, complications (6 urinomas, 8 RDUS, 1 opening of remaining calyxes) required a re-operation in 2 patients. In both groups no conversion to open surgery was reported. Operative time (LPN:166.2 min vs RPN: 255 min; p < 0.001) and hospitalization (LPN: 3.5 days vs RPN: 4.1 days; p < 0.001) were significantly shorter in LPN group. No postoperative loss of renal function was reported in both groups.

CONCLUSIONS

Our results demonstrate that RPN remains a technically demanding procedure with a significantly higher complications and re-operation rate compared to LPN. In addition, length of surgery and hospitalization were significantly shorter after LPN compared to RPN. LPN seems to be a faster, safer and technically easier procedure to perform in children compared to RPN due to a larger operative space and the possibility to perform a complete ureterectomy in refluxing systems.

Retroperitoneoscopic Heminephrectomy in Duplex Kidney in Infants and Children: Results of a Multicentric Survey

PURPOSE

Retroperitoneoscopic partial nephrectomy (RPN) in children is considered a complex technique with limited diffusion among pediatric surgeons and urologists. We aimed to report the outcome of this technique in infants and children with duplex kidney in a 5-year retrospective multicentric international survey.

MATERIALS AND METHODS

Data on 50 children who underwent RPN (41 upper-pole nephrectomies and 9 lower-pole nephrectomies) were retrospectively collected in this six-institution survey. Median age at surgery was 3.3 years. There were 35 girls and 15 boys. The left side was affected in 28 patients, versus the right side in 22 patients. We assessed intraoperative and postoperative morbidity. Follow-up (median, 2.5 years; range, 12 months-5 years) was based on clinical controls and echo color Doppler renal ultrasound scans.

RESULTS

Median duration of surgery was 255 minutes. Surgery was always performed with the patient in a lateral position. Special hemostatic devices were used for dissection and parenchymal section in all centers. Three patients from two centers (6%) required conversion to open surgery. We recorded seven complications (six peritoneal perforations, one opening of the remaining calyxes) in the 50 cases. Re-operation rate was 0%. Average length of hospital stay was 4.1 days.

CONCLUSIONS

Our survey shows that RPN remains a challenging procedure with a long learning curve, performed only in pediatric centers with huge experience in this field. In our survey operative time was longer than 4 hours. The complication rate remains high (7/50, or 14%), with complications classified as Grade II according to the Clavien-Dindo classification. They did not require further surgery, but they were associated with a prolonged hospital stay.

Outcomes in Pediatric Robot-Assisted Laparoscopic Heminephrectomy Compared with Contemporary Open and Laparoscopic Series

PURPOSE

To compare our renal and clinical outcomes for robot-assisted laparoscopic heminephrectomy (RAL-HN) in the pediatric population with duplicated systems with those of current contemporary open and laparoscopic series.

PATIENTS AND METHODS

Sixteen children underwent RAL-HN from 2009 to 2014. Data were collected via retrospective chart review including demographics, preoperative and postoperative imaging, operative time, estimated blood loss (EBL), length of stay (LOS), complications, and renal outcomes.

RESULTS

Mean age at surgery was 37.5±49.2 months. Mean operative time was 135±36 minutes with an EBL of 10±5 mL. Mean LOS was 2±0.8 days, and no major perioperative complications were observed. Mean follow-up was 22.1±17.2 months. Two patients needed secondary ureterectomy for recurrent urinary tract infection in the setting of a refluxing ureteral stump. One of these patients also underwent a ureteral reimplantation of the ipsilateral normal ureter. No patients lost their remaining healthy moiety. Asymptomatic cyst formation was seen in four (25%) patients, and self- limited postoperative urinoma was seen in 2 (13%) patients. Postoperative perinephric abscess did not develop in any patient. Mean change in renal function based on nuclear renography of the duplex kidney was -2.7%±4.6%.

CONCLUSIONS

Compared with previously published literature evaluating open and laparoscopic heminephrectomy, RAL-HN provides comparable outcomes in regard to complication rate and renal function of the remnant moiety.

Laparoscopic transperitoneal heminephrectomy for duplex kidney in infants and children: a comparative study

BACKGROUND AND OBJECTIVE

Evaluation of the feasibility, safety, and outcome of laparoscopic heminephrectomy for duplex kidneys in children above and below the age of 12 months.

PATIENTS AND METHODS

The transperitoneal surgical technique included division of the parenchyma with a sealing device (LigaSure™; Covidien, Mansfield, MA) and amputation of the ureter as low as possible. A follow-up study was performed. Patients' records were analyzed retrospectively for operative details and postoperative complications. Long-term outcome was assessed during follow-up visits and a final telephone interview. Outcome was compared between two groups: Group 1 (G1), age at surgery<12 months; Group 2 (G2), age at surgery >12 months.

RESULTS

Between July 2004 and September 2012, in total, 22 laparoscopic heminephrectomies (20 upper poles and 2 lower poles) were performed in 20 patients (G1, 12 cases; G2, 10 cases). A mean (range) age at surgery was 7.1 (3-11) months in G1 and 49.4 (15-128) months in G2. Mean (range) operative time was 152 (81-220) min in G1 and 197 (90-265) min in G2 (P=.06). All procedures were completed laparoscopically. Major postoperative complication was one urinoma in G1, which was surgically revised. Mean hospital stay was 3.6 days (G1, 4.0 days; G2, 3.1 days). During long-term follow-up (median, 5.2 years) febrile urinary tract infections occurred to the same extent in both groups (G1, 1/12; G2, 2/10; P=.57).

CONCLUSIONS

Laparoscopic transperitoneal heminephrectomy for duplex kidneys is safe and feasible even in small infants. Long-term results are excellent irrespective of the patient's age.

Pediatric open partial nephrectomy: analysis of contemporary outcomes with a supracostal-12 approach

OBJECTIVE

Reports in the literature increasingly have demonstrated a shorter length of stay (LOS) with the laparoscopic approach to partial nephrectomy compared to historic open partial nephrectomy. We present data from the largest open series to date, to provide a more contemporary perspective.

METHODS

A retrospective review was performed on all pediatric patients who underwent upper pole partial nephrectomy from 1999 to 2011. Using univariate and multivariate linear regression, the associations between multiple explanatory covariates and outcomes such as pain and length of stay were analyzed.

RESULTS

Twenty-five surgeries were performed via a supracostal-12 approach. The mean incision length and operative time was 3.7 cm and 137 min, respectively. The average pain score was 1.7/10 and 72% of patients did not require morphine. The mean LOS was 36 h and all patients with postoperative imaging had normal blood flow. Multivariate analysis demonstrated that a later date of surgery was the only covariate significantly associated with decreased operative time and LOS.

CONCLUSION

Open partial nephrectomy can be performed in a minimally invasive manner via a small supracostal-12 incision with minimal pain and LOS. Surgeon experience is associated with decreased operative time and LOS. These contemporary open results should be considered when comparisons are made with laparoscopic surgery.

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.

Transperitoneal laparoscopic heminephrectomy in duplex kidneys: a one centre experience

PURPOSE

The standard treatment for a duplex kidney with poorly functioning upper pole moiety is ipsilateral upper pole heminephrectomy. This procedure is usually performed by open surgery, but with recent developments in techniques of uro-laparoscopy, it can be done with it, safely. In this study we evaluated the results and safety of laparoscopic heminephrectomy in our consecutive cases.

MATERIALS AND METHODS

From February 2001 to May 2007 fourteen unilateral laparoscopic heminephrectomy were performed in our center. Patients' characteristics, presenting symptoms, operative time, and blood loss, early and late complications were all collected retrospectively. Using pre-operative ultrasonography, intravenous pyelography (IVP) and CT scanning, unilateral upper pole hydronephrosis was detected in all cases. By DMSA isotope scan hypofunctioning of ipsilateral moieties was detected in all cases.

RESULTS

Mean operative time was 203±80 minutes. No major intra-operative or early complications were identified. Mean hospital stay was 4.1 days. On mean follow-up of 32 months no disturbing symptoms or episodes of urinary tract infections (UTIs) were detected. Atrophic kidney was detected in one case in post-operative IVP.

CONCLUSION

Laparoscopic heminephrectomy is a valuable minimal invasive procedure that can be performed safely in experienced hands without any important complication. Perfect renal pedicles vascular system manipulation is important for the preservation of renal function post-operatively.

Upper pole nephrectomy: a simplified technique using a retroperitoneal laparoscopic approach

Objective. To describe a simplified technique already used in our institution for several years in the open heminephrectomy for duplication anomalies, now performed through a retroperitoneal laparoscopic approach. Methods. The technique begins with upper pole parenchyma incision since the demarcation between the affected upper moiety and the healthy lower pole is easily established. The dissection proceeds until the urothelium of the collecting system is entered, which will guide further excision, minimizing damage of the surrounding structures. The vascular supply is then identified since the upper pole is attached to the remaining renal parenchyma only by these structures that can be safely divided. Dissection and division of the ectopic ureter is carried next. Results. The operative time was 188 minutes. The blood loss was not significant, and there were no other complications during the procedure. The patient was discharged home 48 hours after the procedure, without any early or late postoperative complications. Conclusion. We believe this simplified technique allows a safer excision of nonfunctioning upper pole renal tissue by avoiding the initial dissection of the renal hilum, which associated with the known advantages of a laparoscopic approach makes us consider it the procedure of choice for upper pole nephrectomy in children.

Paediatric computer-assisted retroperitoneoscopic nephrectomy compared with open surgery

PURPOSE

Computer-assisted laparoscopic surgery (CALS) in children is increasingly used and has proven to be feasible and safe. However, its full potential remains unclear and clinical comparative studies hardly exist. The aim of this study was to prospectively evaluate our experience with CALS for performing retroperitoneal nephrectomies in children when compared with controls undergoing open surgery in terms of safety, operative time, blood loss, opoid requirements, the duration of hospital stay and complications.

CHILDREN AND METHODS

Computer-assisted retroperitoneoscopic nephrectomy was undertaken in ten consecutive children, mean age at the time of surgery 6.4 (SD ± 4.5) years, and compared with a retrospectively collected control group of all other children, mean age 3.9 (SD ± 4.6) years, who underwent the same procedure by conventional open surgery between the years 2005 and 2009. The endpoint of the study was 1 month postoperatively.

RESULTS

Nephrectomies were performed in all the children and no child was excluded from the study. There was no per-operative complication in any of the groups. The median (range) operative time was 202 (128-325) and 72 (44-160) min for the CALS and open group, respectively. The blood loss was minimal (<20 ml) for all the patients. The postoperative opoid requirements did not differ. The median (range) postoperative hospital stay was 1 (1-4) and 2 (1-7) days for the CALS and the open group, respectively. One complication in the form of an urinoma appeared 5 days after surgery in the CALS group.

CONCLUSION

Computer-assisted retroperitoneoscopic nephrectomy is a safe, feasible and effective procedure in children. Even though operative times are longer the patients benefit from the lower morbidity, improved cosmetics and shorter hospitalization associated with the minimally invasive approach.

Outcomes and fate of the remnant moiety following laparoscopic heminephrectomy for duplex kidney: a multicenter review

PURPOSE

To evaluate outcomes following laparoscopic heminephrectomy (LHN) in duplex kidneys in the pediatric population, focusing on the fate of the remnant moiety.

METHODS

142 patients underwent laparoscopic heminephrectomy for duplex kidney across 4 different institutions in the U.S. and Europe. Median age at surgery was 11.4 months. A retroperitoneoscopic approach was used in all patients, with 82 (57.7%) patients placed in posterior prone position (PPR), and 60 (42.3%) in lateral retroperitoneal (LRP). Follow up included routine ultrasound, and DMSA was performed in the event of abnormalities in ultrasound or postoperative course.

RESULTS

Median operative time was 120 min. 11 patients (7.7%) required open conversion, the majority of which (8/11) occurred prior to 2000. Median hospital stay was 2 days and no major complications were observed. 7 patients (4.9%) developed a postoperative urinoma, and 1 patient required ureterectomy for urinary tract infection. With a median follow-up of 4.5 years, 7 children (4.9%) experienced significant loss of function in the remaining moiety, with 3 patients requiring completion nephrectomy. Of patients losing their remaining moiety, median age at surgery was 9 months [4 - 42], and all except 1 (6/7) had an upper pole heminephrectomy. Three patients in this group (42%) experienced an immediate postoperative complication (hematoma, UTI, urinoma). No consistent preoperative or technical factors were consistent in the renal loss group.

CONCLUSIONS

LHN for duplex kidney produces satisfactory outcomes in the pediatric population. With a median follow up of 4.5 years, we demonstrate a non-functioning renal moiety rate of 5%. We did not identify any clinical predictors of this outcome in our series, although upper pole heminephrectomy, patient age, and postoperative complications may be contributing factors.

[Laparoscopic nephrectomy in children]

INTRODUCTION

Laparoscopic nephrectomy in children, not as in the adult population, has evolved more slowly due to the misleading concept that children require small incisions and recover faster. The aim of this article is to present our experience in laparoscopic renal surgery in a paediatric population.

MATERIAL AND METHODS

We checked the clinical records of children that were subjected to laparoscopic renal surgery at our institution between May 1993 and September 2010. We recorded the data prospectively and analysed it retrospectively. The variables we studied were surgical indication, age, sex, procedure and approach, surgery time, hospital stay, intraoperative bleeding, perioperative complications, conversion to open surgery, reintervention and blood transfusion rates.

RESULTS

Between May 1993 and September 2010, we operated a total of 72 patients, 45 nephrectomies (62.5%), 13 nephroureterectomies (18%) and 14 heminephrectomies (19.4%). The mean age was 68 months (range 3-168). The mean surgery time was 80.4 min. (range: 25-270 min.) with a estimated mean blood loss of 37.5 ml (range: 0 -1.000 ml). There were 3 (4.1%) conversions to open surgery. One was due to intraoperative bleeding and the other two were secondary to a difficult dissection due to a history of prior renal surgical interventions. The mean hospital stay was 3.17 days (range: 1-30 days) and there were 7 (9.72%) postoperative complications. There were no deaths.

CONCLUSIONS

We consider the laparoscopic approach for renal surgery in paediatric patients to be a feasible, safe and effective procedure that must be considered as the first option for the treatment of benign pathology in this population group.

Open versus prone retroperitoneoscopic partial nephrectomy in children: a comparative study

PURPOSE

To compare the outcomes of open (OPN) and prone retroperitoneoscopic partial nephrectomy (PRPN) in children.

MATERIALS AND METHODS

The medical and radiological records of all children undergoing OPN and PRPN over a 6-year period (2002-2008) were reviewed.

RESULTS

Thirty-nine (11 boys/28 girls) partial nephrectomies were performed in a single institution. There were 24 OPNs (15 upper, 9 lower) and 15 PRPNs (13 upper, 2 lower) with a median age at surgery of 2.3 years and 3.4 years, respectively. Median duration of surgery was 50 min (range 30-180) for the OPN and 150 min (range 70-205) for the PRPN (P < 0.001). Median postoperative hospital stay was 4 days (range 2-7) for the OPN and 2 days (range 1-5) for the PRPN (P < 0.001). One patient in the OPN underwent a total nephrectomy with a loss of the remaining moiety. In 20 (87%) patients of the OPN group an epidural infusion was administered and four required a morphine infusion, while only five patients in the PRPN group required a morphine infusion.

CONCLUSIONS

Open partial nephrectomy had a significantly shorter operative time, but it was associated with a longer postoperative stay and higher analgesia requirements when compared to PRPN.

Retroperitoneal laparoscopic upper-pole nephroureterectomy for duplex kidney anomalies in adult patients

OBJECTIVES

To present our surgical techniques and experience with retroperitoneal laparoscopic upper pole nephroureterectomy for a duplex kidney in adult patients without vesicoureteral reflux.

METHODS

A total of 32 adult patients with a duplex kidney underwent laparoscopic upper pole nephroureterectomy. A 3-port, finger- and balloon-dissecting, retroperitoneal approach was used. The upper pole renal parenchyma was divided circumferentially between the upper and lower poles using a harmonic scalpel, maintaining a margin around the upper pole parenchyma to avoid any possible injury to the lower pole functioning moiety. The urothelium of the remnant upper pole parenchyma was stripped off, and the edges of the remnant upper pole parenchyma were approximated with figure-of-8 stitches. The distal upper pole ureter was mobilized and transected at the point at which the ureter crossed anterior to the iliac vessels. Intravenous urography and renal ultrasonography were performed at 3 and 6 months postoperatively.

RESULTS

All laparoscopic operations were performed successfully without conversion to open surgery. The mean operative time was 83 minutes. The mean blood loss was 18 mL. The mean postoperative hospital stay was 7 days. No intraoperative or major postoperative complications occurred. The intravenous urography and renal ultrasound findings 3 and 6 months postoperatively demonstrated normal pyelography findings and renal function of the preserved lower pole in all patients.

CONCLUSIONS

Retroperitoneal laparoscopic upper pole nephroureterectomy is a safe and effective procedure and an excellent minimally invasive treatment option for the adult patient with a duplex kidney.

Transperitoneal laparoscopic heminephrectomy in duplex kidney: our initial experience

OBJECTIVES

To study the feasibility, safety, and effect of transperitoneal laparoscopic heminephrectomy in the duplex kidney.

METHODS

From December 2003 to January 2008, 18 patients with urinary tract duplex anomalies underwent laparoscopic heminephrectomy using a transperitoneal approach. The sites of surgery consisted of 6 right upper, 2 right lower, 9 left upper, and 1 left lower heminephrectomy. Follow-up studies were performed using renal ultrasonography in all patients.

RESULTS

All patients underwent laparoscopic surgery successfully without conversion to open surgery or intraoperative complications. The mean operative time was 142.8 minutes (range 90-195). The mean estimated blood loss was 196.1 mL (range 20-600), and the mean hospital stay was 6.1 days (range 4-10). In 1 patient, a minor postoperative urine leak resolved spontaneously with prolonged catheter drainage. The radiologic assessment showed normal ipsilateral renal growth in 18 patients at a mean follow-up of 25.8 months.

CONCLUSIONS

Our initial clinical experience suggests that laparoscopic heminephrectomy using a transperitoneal approach for the duplex kidney is feasible, safe, and effective. Therefore, the transperitoneal approach for moiety excision, which offers a technically simple approach for complete ureterectomy, is recommended.

Laparoscopic transperitoneal partial nephrectomy in children under 2 years old: a single-centre experience

OBJECTIVE

To report our experience with laparoscopic transperitoneal (TP) heminephrectomy for duplicated pyeloureteral systems in children under 2 years old.

PATIENTS AND METHODS

We retrospectively reviewed the intraoperative evolution and patient outcome of 10 laparoscopic partial ureteronephrectomies (7 upper and 3 lower pole nephrectomies) using a TP approach, performed over 4 years. Mean age at surgery was 9.1 months (range 3.5-20.4), with seven children younger than 1 year. Average follow up based on clinical examinations and renal ultrasounds was 13.9 months (range 1.2-38.5).

RESULTS

The average operative time was 123 min (range 90-195). There was no need for conversion and no intraoperative complications. Mean postoperative hospital stay was 2.9 days. A perirenal collection with spontaneous regression occurred in one case. The main postoperative complication consisted of a diminution in renal function with pyelic dilation in a 4-month-old child, due to inadequate positioning of the remaining moiety. This child remains asymptomatic 3 years after surgery.

CONCLUSIONS

We recommend a TP approach for laparoscopic heminephrectomy due to the improved vascular exposure and control, diminished need for renal mobilization, and greater working space that can be obtained, especially in toddlers with a higher morbidity rate caused by the lack of retroperitoneal space.

Heminephroureterectomy for duplex kidney: laparoscopy versus open surgery

OBJECTIVE

To report our experience of laparoscopic heminephroureterectomy (Hnu) in pediatric patients with duplex anomalies, in comparison to open surgery.

PATIENTS AND METHODS

Retrospective review of data from patients who underwent Hnu from 2005 to 2008 was performed. The patients were divided into two groups: laparoscopic (LHnu) and open surgery (OHnu). Laparoscopic surgery was performed by transperitoneal approach in majority of cases. Open surgery was performed by retroperitoneal approach in all cases.

RESULTS

Group LHnu: nine patients (8 females, 1 male) with median age of 14 months (range 3-205). Transperitoneal approach was performed in eight patients. Mean operative time was 182 min (CI 95% 146-217). No conversion to open surgery was necessary and there were no complications. Mean hospital stay was 2.44 days (CI 95% 1.37-3.52). Group OHnu: eight patients (3 females, 5 males) underwent nine heminephrectomies at median age of 6.9 months (range 1-12). Mean operating time was 152 min (CI 95% 121-183). There were no complications and mean hospital stay was 4.38 (CI 95% 2.59-6.16) days. Statistical analysis showed no statistically significant difference (P>0.05) in operating time between groups while mean hospital stay was significant (P=0.021).

CONCLUSION

The laparoscopic approach is feasible, safe, reduces hospital stay, does not increase operating time and has better cosmetic results. We believe this should be the first option for heminephrectomy.

Prone retroperitoneoscopic approach for heminephrectomy: specific advantages relating to access to vascular pedicle

INTRODUCTION

The lateral approach is more widely used in retroperitoneoscopic (RP) heminephroureterectomy (HNU) due to familiar orientation and ease of conversion. The prone approach however gives early and easy access to the vascular pedicle. The main reason for not adopting a prone approach more widely is the perceived difficulty in lower ureteric access. We present a series of 30 HNUs where the prone approach was utilized extremely effectively with no conversions and few complications.

METHODS

Thirty consecutive HNUs performed over a 4-year period (2004-2007) using a prone RP approach were included in the study. Prospectively recorded data and notes were reviewed.

RESULTS

Upper HNU was done in 17 and lower HNU in 13 patients. Mean age was 3.2 years (range 0.9-13.3). There were no transfusions or conversions. Follow-up ultrasound showed healthy remnant moieties in all. Residual ureteric stump was seen in six patients but only one was symptomatic requiring a further procedure.

CONCLUSION

With the prone approach the anatomy can be demonstrated quickly and effectively. Dissection can be done easily without the need for kidney retraction as gravity aids demonstration of the renal vascular pedicle. There is a low risk of complications arising from the residual ureteric stump. We recommend that this approach be considered for RP HNU in all patients, irrespective of age.

Laparoscopic heminephrectomy for benign renal anomalies

BACKGROUND AND PURPOSE

Benign renal conditions, such as duplication and fusion anomalies, are relatively common and may lead to problems such as chronic flank pain or urinary tract infection. Traditional management of these conditions has been open surgical removal of the affected moiety. As an alternative, we report on our experience with laparoscopic heminephrectomy for benign renal anomalies and emphasize the technical aspects of the procedures.

PATIENTS AND METHODS

We retrospectively reviewed the records of patients who underwent laparoscopic heminephrectomy for benign renal anomalies at our institution between February 1999 and April 2009.

RESULTS

Heminephrectomy was performed in 11 patients, including 8 with duplicated collecting systems, 2 with horseshoe kidneys, and 1 with a cross-fused renal ectopic kidney. Median operative time was 204 minutes, and median estimated blood loss was 250 mL. There were no intraoperative complications. The presenting symptoms resolved in all patients. There were three major and two minor postoperative complications, including 50% loss of remaining ipsilateral renal parenchyma, postoperative neuralgia and anejaculation, urinoma, and partial wound separation. Median length of hospital stay was 2 days. Renal function was well preserved in all patients. The median change in serum creatinine level was 0.1 mg/dL.

CONCLUSIONS

Although laparoscopic heminephrectomy is challenging because of the variable blood supply and abnormal anatomy of the kidney, with careful planning and attention to detail, the procedure is safe and effective for the management of a wide range of benign renal anomalies that necessitate heminephrectomy and offers the usual recovery advantages of laparoscopy.

[Complications in laparoscopy renal surgery in pediatric age: analysis of our experience and literature review]

INTRODUCTION

The development of the minimally invasive surgery in pediatric age has been slower than in the adult age since their advantages are not so clear. The learning curve and the complications presented during this period, as well as the type of material used has been the factors that have contributed to this fact.

OBJECTIVE

We collected our experience and the complications presented in renal laparoscopic exegesis surgery, adding a review of the published literature to date.

MATERIALS AND METHODS

Retrospective study of our clinical cases in that we practiced laparoscopic renal exegesis surgery. We collected 56 cases from January 2003, when it was implanted, to September 2008. We had 36 boys (64%) and 20 girls (36%). The mean age was 3.6 years. We analyzed principal diagnosis, the situation that conducted to the surgery and the type of surgery performed, time of surgery, hospital stay and complications with their solution. The results were analyzed the statistical program SPSS (SPSSCorp, Chicago, Illinois). The literature review was practiced in MEDLINE, EMBASE and COCHRANE database. The selected works were reviewed by two investigators. Series containing adults were excluded.

RESULTS

We perfomed 42 nephrectomies (75%), 13 heminephrectomies (23%) and 1 quistectomy (2%). 5 cases (9%) were done by retroperitoneoscopy and 51 cases (91%) transperitoneally. The mean operative time was 118 +/- 0,75 min, for nephrectomies; 192 +/- 1.07 min, for partial nephrectomies, 111 +/- 0,64 for nephroureterectomies and 240 min for quistectomia. The mean hospital stay was 3.18 min (2-6) days for nephrectomies; 5.91 (3-11) days for partial nephrectomies, 3 days (2-4) for nephroureterectomies and 6 days for the quistectomy. We had 8 complications (14%): 2 conversions for bledding and technical difficulty and 6 postoperative complications (3 were minor complications, postoperative fever and 3 mayor (2 Urinomas and one pseudoaneurism, requiring 2 interventions and one catheter double J placement). The evolution has been satisfactory in all cases. In the bibliographic review 47 articles with a level of evidence IIIB were selected (Oxford Centers for Evidence-based Medicine). The main reasons to conversion to open surgery were vascular problems and the complication rate change from anyone to 37%.

CONCLUSIONS

Laparoscopic surgery has proved to be a secure and feasible technique in the treatment of benign renal pathology in pediatric age with satisfactory results. Actually the indications are expanding to reconstructive procedures, with promising results, and selected oncologic procedures.

Laparoscopic heminephroureterectomy for duplex kidney anomalies in the pediatric population

OBJECTIVE

Despite increasing acceptance of laparoscopy in pediatric urology, few published data are available on laparoscopic heminephroureterectomy in patients with duplex kidney anomalies. In the present study, we report our own experiences with this technique.

PATIENTS AND METHODS

From August 2003 to January 2006, five laparoscopic heminephroureterectomies were performed in four girls with a mean age of 41 (9-67) months. In all cases, a non-functioning upper pole with an obstructive (n=4) or refluxing (n=1) megaureter was found. The upper pole was resected laparoscopically en bloc with the megaureter using three to four trocars.

RESULTS

Mean follow-up was 42.4 (+/-7.9) months. All procedures were performed successfully without conversion to open surgery with a mean operative time of 190 (170-210)min. Blood loss was minimal and no intraoperative complications occurred. Despite chronic inflammation in the resected specimens, the patients showed no clinical signs of infection postoperatively. The average length of hospital stay was 5.6 (4-7) days. All patients were followed using duplex sonography.

CONCLUSIONS

These data demonstrate that, even in infants, laparoscopic heminephroureterectomy is feasible and associated with minimal morbidity, a better cosmetic result and a shorter hospital stay compared to open surgery. The main disadvantage of the laparoscopic approach is a longer operative time. Laparoscopic heminephroureterectomy is a technically demanding procedure and should be performed only in specialized centers.

Retroperitoneal laparoscopic heminephrectomy in duplex kidney in infants and children: a 15-year experience

BACKGROUND

Laparoscopic retroperitoneal partial nephrectomy in children remains a complex technique with limited diffusion among the paediatric surgical community.

OBJECTIVE

To report our experience with laparoscopic heminephrectomy in duplex kidneys after a 15-yr practise of the technique in children and infants.

DESIGN, SETTING, PARTICIPANTS

Forty-eight children with retroperitoneal laparoscopic partial nephrectomy (36 upper-pole nephrectomies [UPN] and 12 lower-pole nephrectomies [LPN]) were retrospectively included in this single-institution study. Median age at surgery was 8.6 mo (range 1.5-89), with a policy of early surgical intervention for UPN in cases involving a massively dilated upper tract.

INTERVENTION

Retroperitoneal laparoscopic partial nephrectomy for duplex kidney in lateral position (n=31) and prone in the last 17 cases.

MEASUREMENTS

We assessed intraoperative and postoperative morbidity. Follow-up (median 14 mo, range 6-125 mo) was based on clinical review and renal ultrasound.

RESULTS AND LIMITATIONS

Median duration of surgery was 120 min (range 71-215). Ten procedures (21%) were converted into open surgery, mostly at the beginning of the experience (eight during the first 20 cases, as compared to one conversion in the last 20). Among four converted LPNs, three were converted for difficulties during parenchymal section. Six UPN were converted for difficulties of exposure, with a strong correlation with age: all six were infants, with a median age of 3.25 mo (range 1.5-8 mo). We observed one case (case 4) of functional loss of the remaining lower moiety.

CONCLUSIONS

This study shows a high conversion rate during the learning curve for laparoscopic heminephrectomy. Retroperitoneoscopic UPN remains a challenging procedure in children, especially in small infants with very dilated collecting systems. The possibility of vascular damage to the remaining moiety warrants a very cautious dissection of the renal pedicle and should lead to conversion when clear visualization of vascular anatomy is not ascertained.

The role of laparoscopic surgery for urinary tract reconstruction in infants weighing less than 10 kg: a comparison with open surgery

PURPOSE

To compare the outcome of laparoscopic urinary tract reconstruction (LUTR) in children weighing 10 kg or less with a weight-matched cohort undergoing open urinary tract reconstruction surgery (OUTR).

MATERIALS AND METHODS

We conducted a retrospective chart review of patients weighing 10 kg or less at the time of surgery who underwent open or laparoscopic pyeloplasty, transuretero-ureterostomy and ipsilateral uretero-ureterostomy between January 2000 and May 2007. The following information was recorded: body weight, age, sex, diagnosis, type of procedure, operative time, estimated blood loss, pre- and postoperative hemoglobin levels, length of hospitalization, length of follow up, use of drains and stents, intraoperative and postoperative analgesic requirement, need for readmission, subsequent procedures, costs, complications and reoperations.

RESULTS

There were 52 patients divided into two groups: LUTR (n=23) and OUTR (n=29). Median weight (range) and follow up was 6.2 kg (3.9-10) and 9 months and 6.5 kg (4.7-9.6) and 31 months for LUTR and OUTR, respectively. Mean operative time for LUTR (including cystoscopy and stent placement) was 237 min and for OUTR 128 min (P<0.01). There were no differences in blood loss, intra- or postoperative analgesic requirement, results or complications. Mean hospitalization time was shorter for LUTR than OUTR (2 and 3 days, respectively). There were no differences in hospital costs between the two groups.

CONCLUSIONS

Laparoscopic reconstructive surgery for congenital urological anomalies is safe and effective in small infants and can be performed with outcomes comparable to that of open surgery.

Pediatric transperitoneal laparoscopic partial nephrectomy: comparison with an age-matched group undergoing open surgery

We have retrospectively evaluated the effectiveness of laparoscopic transperitoneal partial nephrectomy (LTPN) in children in comparison to an age-matched group of children who underwent open partial nephrectomy (OPN) in terms of safety, operative time, narcotic requirements and the length of hospitalization. All patients were divided into two groups. The first group of 10 children with a mean age of 3.6 +/- 1.3 years (mean +/- SEM) who underwent LTPN compared with an age and gender matched second group of 10 children with a mean age of 3.9 +/- 1.4 years who underwent OPN (P = 0.9119). In the first group, 5 upper poles and 5 lower poles partial nephrectomies were performed while in the second group 6 upper moieties and 4 lower moieties partial nephrectomies were performed, respectively. There was a single complication in each group. Intraoperative injury to the unaffected ureter was recognized during LTPN and required conversion to the open surgery in the beginning of learning curve and persistent urinary leakage from collecting system of the remnant pole in the OPN group, which resolved spontaneously. There was no difference in length of surgery and the intraoperative narcotic requirements (P = 0.8182, 0.7638, respectively). However, postoperative narcotic requirements were significantly lower in the first group 0.56 +/- 0.29 mg/kg compared to the second group 2.13 +/- 0.3 mg/kg, P = 0.0019. LTPN patients had significantly shorter hospitalization 2.7 +/- 0.29 days compared with the OPN group 5.1 +/- 0.64 days, P = 0.0039. Similar findings were also found in the subgroup of patients younger than 2 years. Median follow up in each group was 28 and 36 months, respectively. Our data show that LTPN is a safe and effective minimally invasive procedure at every age. It has an equivalent operative time, shorter hospitalization and lower postoperative narcotic requirements compared to the open approach.