Pediatric retroperitoneoscopic nephrectomy

Comparison between closed and open techniques for creating a retroperitoneal space for retroperitoneoscopic renal surgery in children

AIM

During retroperitoneoscopic renal surgery (RPRS), the open technique (OT) for trocar insertion is always associated with CO2 leakage around the first trocar, while the closed technique (CT) involves advancing an optical trocar into the retroperitoneal space (RS) under direct vision. We are the first to compare OT with CT.

METHODS

Forty-one cases of RPRS performed for pyeloplasty (31), hemi-nephrectomy (4), nephrectomy (4), stone removal (1), and cyst excision (1) were studied. The initial 5 mm trocar was inserted using OT (n = 11) or CT (n = 30). The tip of a telescope was used for blunt dissection of the retroperitoneum to create the RS.

RESULTS

Ages and weights at RPRS were similar (OT versus CT: 7.3 versus 7.1 years; 25.4 versus 25.0 kg; respectively). In CT, RS access was significantly faster (38.2 versus 5.6 min), RS was created significantly quicker (77.7 versus 31.9 min), and narcotic usage was significantly less (4.0 versus 1.5 days). In OT, CO2 leaked in 11/11 and the retroperitoneum was torn in 3/11. In CT there was no leakage and no tearing.

CONCLUSIONS

CT is quicker and safer than OT during RPRS.

Prone retroperitoneoscopy in treating complex renal vascular malformations

INTRODUCTION

Two children presented with malignant hypertension due to complex reno-vascular malformations. The 7-min video shows the use of prone retroperitoneoscopy in both. PATIENT 1: A 6-year-old girl presented with convulsions and malignant hypertension. Captopril DMSA was suggestive of right renal artery stenosis. On formal angiography, the kidney was perfused by what appeared to be an arterio-venous malformation. The renal artery was hypoplastic and there were pulsatile vessels along the ureter due to the gonadal periureteric and gonadal inferior capsular collateral supply to the kidney. The kidney could be devascularized easily by controlling these. PATIENT 2: A 14-month-old boy presented with 6-month history of poor appetite, weight loss and irritability. Formal angiography showed acute obstruction of the main upper pole branch. The vessels to the upper pole could be clearly seen and controlled at surgery for partial right nephrectomy. He recovered with no urine leak or bleeding.

CONCLUSION

Gravity kept the renal vessels under stretch allowing excellent two-hand dissection and the space was adequate for suture closure of a calyx in Case 2. The prone approach provides excellent exposure of the renal blood vessels, aorta and vena cava, and seems to be the most suitable for complex renal vascular malformations.

Retroperitoneoscopic adrenalectomy: an early institutional experience

OBJECTIVE

To review our initial experience with the retroperitoneoscopic approach, which is rapidly becoming the procedure of choice for paediatric adrenalectomy. Swift access to the vascular pedicle makes this approach ideal for adrenal surgery where haemodynamic instability is a common feature.

METHOD

Patients were placed in a fully prone position and the locations of the 12th rib, iliac crest and paravertebral muscles were marked. A 10-mm incision was made lateral to the para-vertebral muscle, halfway between the iliac crest and costal margin. A retroperitoneal working space was created around the kidney using a homemade balloon. A 10-mm Hasson port was then inserted. A 5-mm working port was placed lateral to the tip of the 12th rib and, if necessary, a second was inserted medial to the camera port. Dissection was performed with diathermy and/or Harmonic Scalpeltrade mark and the adrenal vessels were divided between clips. The specimen was retrieved in an endopouch through the 10-mm port.

RESULTS

Over 16 months, six adrenalectomies were performed in five patients (three boys and two girls); two right, two left and one bilateral. Median age at surgery was 8 years. Presentation was with hypertension (n=2), Cushing's syndrome (n=2) and abdominal pain (n=1). Median operative time was 154 min. A single-instrument port adrenalectomy was performed in three patients. Histopathological diagnosis included adrenal cyst (n=1), cystic phaeochromocytoma (n=1), adrenal cortical tumour (n=2) and central Cushing's disease (n=1). All were completely resected. All patients remain symptom free with a median follow up of 17 months.

CONCLUSION

These cases represent our initial institutional experience with retroperitoneoscopic adrenalectomy. The senior reporting surgeons have already surmounted the general learning curve for laparoscopy, and this experience has proved vital to expand our repertoire with encouraging early results. This is our technique of choice as it provides a superior view of the adrenal gland and vessels, with good intraoperative haemodynamic stability.

Laparoscopic and robotic approach to genitourinary anomalies in children

The evolution of laparoscopic surgery in pediatric urology has been long and slow, but is emerging steadily and seems to be here to stay. This article reviews the basic applications of laparoscopic methods in pediatric urology, including diagnostic and operative procedures. The new horizons of robotic assistance for laparoscopic surgery make highly accurate and efficient reconstructive procedures possible.

A modified access technique for retroperitoneoscopic renal surgery in children

PURPOSE

Present techniques for retroperitoneal endoscopic (RPE) access in children mimic those in adults but often result in peritoneal entry or gas leaks, both of which lead to a decrease in the retroperitoneal space. We describe a modification to the access technique that obviates these problems, thus, facilitating RPE in children.

MATERIALS AND METHODS

In the lateral decubitus position the initial port is placed immediately lateral to the paraspinal muscles, similar to open dorsal lumbotomy fascial incision. A 5 mm skin incision is made at the level of the costovertebral angle and an artery forceps used to tunnel bluntly past the lumbodorsal fascia. A 5 mm port is placed with a blunt trocar, and expansion of the retroperitoneal space performed with the telescope and gas insufflation. Ancillary ports are placed and the telescope then moved to an anterior subcostal port where popular RPE approaches place the initial port.

RESULTS

Eighteen procedures were performed in children with a mean age of 10.8 years, including 12 nephrectomies, 3 dismembered pyeloplasties, 1 partial nephrectomy, 1 nephroureterectomy and 1 parapelvic cyst decortication. No gas leaks occurred, with 1 minor peritoneal entry early in the series not related to the access. Average surgical time for nephrectomy was 178 minutes (range 120 to 240). No intraoperative complications occurred.

CONCLUSIONS

We present a safe and effective technique of initial port placement that follows the principles of open lumbotomy exposure. This approach to RPE minimizes peritoneal entry and gas leaks, thus, maximizing surgical exposure.

New surgical techniques in pediatric urology

More sophisticated endoscopic instruments, combined with a better understanding of bladder and urethral pathology, have significantly improved the therapeutic approaches for both posterior urethral valves and ureteroceles. New generation lithotripters have allowed for a safe and efficient method of treating urinary calculi in children, which was once thought too injurious a process with first-generation machines. The rapidly advancing field of laparoscopy, aided by the development of more optically refined and diminutive instruments, has allowed for its application in a wide variety of surgical interventions in pediatric urology. The tubularized incised plate urethroplasty has challenged more traditional approaches to hypospadias repair and is now considered by many pediatric urologists to be the best approach for midshaft and distal hypospadias. The one-stage approach to exstrophy repair may hold the answer to improved continence without a formal bladder neck reconstruction. Finally, the field of tissue engineering leads the way to new advances in autologous biological substitutes in the surgically-challenged patient where there is a shortage of local tissues at the surgeon's disposal.