Elsevier

European Urology

Volume 56, Issue 2, August 2009, Pages 385-391
European Urology

Pediatric Urology
Retroperitoneal Laparoscopic Heminephrectomy in Duplex Kidney in Infants and Children: A 15-Year Experience

https://doi.org/10.1016/j.eururo.2008.07.015Get rights and content

Abstract

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.

Introduction

Partial nephrectomy is a well-established option for the treatment of nonfunctioning renal moieties in duplex kidneys. Most indications of heminephrectomies in duplex kidneys are represented by high-grade reflux in lower moieties, and nonfunctioning upper moieties caused by ureterocele or ectopic distal implantation of the ureter. Even though laparoscopy has become the standard approach for total nephrectomy in children [1], minimally invasive techniques have not expanded so widely in the paediatric surgical community for heminephrectomies. Now, 15 yr after the first report of a laparoscopic partial nephrectomy in a child [2], the technique seems to remain confined to the hands of experienced teams, with a limited number of reports including relatively few cases.

Partial nephrectomy is a complex procedure, with a risk of urine leak, haemorrhage, and vascular injuries leading to functional loss of the remaining moiety [3]. Some reports have questioned the superiority of the laparoscopic technique in terms of length of procedure [4] and incidence of complications [5]. We report our experience with retroperitoneal laparoscopic partial nephrectomy in a nonselected population of infants and children over a 15-yr period.

Section snippets

Methods

We retrospectively reviewed all consecutive cases of partial nephrectomy performed through retroperitoneoscopy in our department. A total of 48 retroperitoneoscopic heminephrectomies (36 upper-pole and 12 lower-pole nephrectomies) were performed between 1993 and 2007, at a median age of 8.6 mo (range 1.5–89). These were unselected consecutive cases, no case of partial nephrectomy having been performed by open conventional surgery since 1999 in our unit. Forty-seven of the 48 procedures were

Results

The median duration of surgery was 120 min (range 70–215 min) with a slight tendency to decrease with experience (r2 = 0.23) (Fig. 1). Most children restarted feeding the same day as surgery (n = 24) or the day after (n = 22). The median length of hospital stay was 3 d (range 2–13 d), with 24 children discharged at day 2 and 13 at day 3 postoperatively.

Discussion

Although minimally invasive techniques have proven beneficial in several indications in adults and children, it seems that the diffusion of laparoscopic partial nephrectomy remains limited to centres with advanced laparoscopic experience. This may be related to the procedure's high level of technical difficulty combined with a relatively small number of indications, but also to a lack of evidence regarding the true benefits of the procedure. Although a few pioneering centres have reported on

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