Introduction

Laparoscopy in pediatric urology began in 1976, when Cortesi et al. reported diagnostic laparoscopy to evaluate nonpalpable testes [1]. Since then, laparoscopy in children has gained widespread popularity. It has become a safe and effective approach for several different pediatric urologic procedures.

In 1991, Bloom introduced laparoscopic ligation of testicular vessels for first‐stage Fowler–Stephens [2]. A year later, Jordan and Winslow described the first laparoscopic orchiopexy [3]. Work by these early pioneers led to diagnostic laparoscopy becoming the gold standard approach to evaluating nonpalpable testes. More importantly, laparoscopic orchiopexy, whether single or staged, has become an advantageous approach to treating high intra‐abdominal testes [4, 5].

In its infancy, laparoscopy was adopted slowly by pediatric urologists. The instruments were cumbersome and limited, making the procedures technically challenging laparoscopically, while open surgery had very high success rates. Today, with the advancements of minimally invasive tools for pediatric patients, new technology, and increase in surgeon experience, laparoscopy has found a niche in pediatric urology as a safe, effective, and well‐established alternative to many pediatric urologic procedures beyond orchiopexy, including nephrectomy, partial nephrectomy, pyeloplasty, hernia repair, varicocelectomy, bladder reconstruction, and antireflux surgery [6, 7]. The first pediatric laparoscopic nephrectomy was described by Koyle et al. in 1993 [8].

In July 2000, the US Food and Drug Administration approved the use of the da Vinci™ Surgical System (Intuitive Surgical Inc., Sunnyvale, CA, USA). Robotic surgery has now replaced several of these laparoscopic procedures, but laparoscopy still has a role to play.

Safety and efficacy

Initial criticism towards laparoscopy included the longer operative times and high success rates with open procedures through small incisions that obviated the need for a minimally invasive approach. In the hands of skilled surgeons, the benefits of pediatric laparoscopy are similar to those in adults: it offers decreased incisional pain, shorter recovery times, and enhanced cosmesis [9, 10].

Complications rates are relatively low. Laparoscopic orchiopexy is still the most common laparoscopic procedure performed by pediatric urologists, and success rates are as high as 90% with complications rates less than 3.0% [11]. Peters reported a complication rate of 5.4% in 5400 pediatric urologic laparoscopic cases. This number decreased to 1.2% once preperitoneal insufflation was excluded. This same study found that surgeon experience was the strongest predictor of complication rates [12]. In a recent systematic review, Kim et al. reported a complication rate of 3.5% in transperitoneal laparoscopic renal surgery [13]. In a prospective study by Penn et al., laparoscopic pyeloplasty was found to be a safe and effective alternative to open approach, providing shorter hospital stays and similar postoperative outcomes [14].

Indications

As mentioned above, laparoscopy has become the gold standard for evaluating nonpalpable testes. It provides a quick assessment of intra‐abdominal space through a small incision at the umbilicus (Figure 115.1). If an intra‐abdominal testis is discovered, the size and location are noted and the decision to proceed with laparoscopic single or staged orchiopexy can be made. If blind‐ending vessels are noted in the rare case of vanishing testes, then no further action is needed and the patient spared an extrainguinal incision for exploration [4, 15].

Laparoscopic nephrectomy is usually indicated for removal of nonfunctioning kidneys secondary to obstruction, ureteral ectopia, or vesicoureteral reflux. The approach can be transperitoneal or retroperitoneal, with the former affording lower complication rates [13]. Laparoscopic nephroureterectomy and partial nephrectomy is performed to remove upper or lower pole moieties that are obstructed and nonfunctioning. Many authors argue that visualization of the renal vessels and moieties in a duplex system is much clearer laparoscopically than in open, helping to decrease the potential risk of vascular injury [15].

Laparoscopic pyeloplasty was first introduced by Peters in 1995 for treatment of ureteropelvic junction obstruction [16]. The procedure is technically challenging, but has good surgical outcome in high‐volume centers [14]. This procedure has been replaced by a robot‐assisted approach, but at several institutions around the world where robotics are unavailable, laparoscopic pyeloplasties are still being performed.

Other uses for laparoscopy include ureteral reimplantation, ligation of spermatic vessels for varicoceles, and reconstructive cases. Laparoscopic continence antegrade enemas and appendicovesicostomies have high success rates, decreased postoperative wound issues, and shorter convalescence times than the more morbid open procedures. Laparoscopic approach allows access to both upper and lower parts of the abdomen without having to make a large midline incision [17, 18].

Anatomical and physiologic considerations

When considering a minimally invasive approach in children, one must be cognizant of the anatomic and physiologic differences between pediatric and adult populations. Pneumoperitoneum can produce significant changes to cardiac, respiratory, and autonomic physiology that must be recognized by both surgeons and anesthesia team.

Pneumoperitoneum can decrease ventricular preload, and although in children with normal cardiac function the changes are well compensated and the effects are negligible, in patients with congenital heart defects the result can be deleterious [19]. Moreover, abdominal distention can spark increased vagal tone and subsequent bradycardia, which can further decrease cardiac output in patients with cardiac insufficiency [20]

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