Pediatric Laparoscopic Nephrectomy and Partial Nephrectomy
GLENN M. CANNON JR.
RICHARD S. LEE
Since the initial description of a laparoscopic heminephrectomy in a 14-year-old by Jordan and Winslow in 1993 (1), a large amount of literature has been devoted to laparoscopic renal ablative surgery in children. With its decreased length of stay, decreased postoperative opioid requirements, improved cosmesis, and equivalent operative times to open surgery, laparoscopic nephrectomy and partial nephrectomy have become widespread procedures in pediatric urology. In a cost analysis from the United Kingdom, the laparoscopic approach to nephrectomy in children was 54% less expensive than the open approach (2). Currently, robotic systems such as the da Vinci Surgical System (Intuitive Surgical, Sunnyvale, California) are being utilized for more complex reconstructive procedures such as partial nephrectomy. Future research will determine its utility as compared to conventional laparoscopy.
DIAGNOSIS
Children with prenatal or postnatal hydronephrosis and/or febrile urinary tract infection are often imaged with renal ultrasound, voiding cystourethrogram (VCUG), and possibly radionucleotide renal scanning. If there is no evidence of vesicoureteral reflux (VUR), nuclear renography is performed to determine if there is significant obstruction and/or salvageable function. If a clinically significant nonfunctioning renal moiety (e.g., <5% to 10% function by dimercaptosuccinic acid study) is identified, nephrectomy or partial nephrectomy may be considered. Further imaging is usually not warranted, unless there is a history of a continued day and night wetting and possible ureteral ectopia. In these instances, magnetic resonance imaging (MRI) urography may be beneficial (3). In cases of a renal mass, abdominal computed tomography (CT) or MRI is typically obtained to further delineate the mass. In all cases, particular attention should be paid to vascular anatomy, the presence and appearance of the contralateral kidney, the presence and appearance of the ipsilateral and contralateral adrenal glands, and any degree of lymphadenopathy.
INDICATIONS FOR SURGERY
Indications for laparoscopic nephrectomy or partial nephrectomy in children include nonfunctioning kidney, poorly or nonfunctioning upper or lower pole moieties associated with duplicated collecting systems, or renal mass. Typical causes include obstruction, reflux, or ureteral ectopia. Symptoms can possibly include pain, hypertension, infections, or stone formation. Laparoscopy can also be applied when bilateral nephrectomy is required of nonfunctioning kidneys causing hypertension, infections, or nephrotic syndrome prior to renal transplantation. Removal of potentially malignant renal masses has not typically been approached in a laparoscopic fashion in children.
ALTERNATIVE THERAPY
Open nephrectomy or partial nephrectomy is the alternative to a laparoscopic approach. Percutaneous renal ablative procedures such as cryogenic and radiofrequency ablation are not performed in children. An open procedure may be considered if the kidney is large or extensive intra-abdominal adhesions are present. Retroperitoneal laparoscopy can be considered if there is a history of previous abdominal surgery, and transperitoneal laparoscopy can be considered if there is a history of retroperitoneal open surgery.
SURGICAL TECHNIQUE
The following descriptions refer to laparoscopic partial nephrectomy in children. Specific mention is made when the steps of the procedure differ from the performance of a complete nephrectomy. Otherwise, the steps are identical. Although ultimately the surgical approach will be chosen by an individual surgeon’s comfort level and experience, Borzi and Yeung (4) proposed selecting an approach based on the specific type of procedure performed. Reporting an experience of 179 laparoscopic procedures, they recommended a posterior retroperitoneal approach for isolated renal excision without extended ureterectomy, a lateral retroperitoneal approach for complete ureterectomy or access to horseshoe and pelvic kidneys, and a transperitoneal approach when complete moiety excision with lower urinary reconstruction is planned.
Transperitoneal Approach
Preoperatively, patients receive a clear liquid diet for 24 hours and a rectal suppository the night before surgery. Depending on surgeon preference, cystoscopy is performed prior to the start of the partial nephrectomy. A ureteral stent can be placed in the nonfunctioning moiety to assist in identification if necessary. A bladder catheter and orogastric tube are placed.
The affected side is elevated by a 30-degree wedge, and the patient is carefully secured to the operating table. The table is rotated to flatten the patient’s abdomen. With the patient’s
abdomen flat, transperitoneal port access is gained using either a Veress needle or with the modified Hasson technique. A camera port (12 mm) is placed at the umbilicus (Fig. 103.1). A second port (5 or 8 mm) is placed superior to the umbilicus in the midline approximately 10 cm from the umbilical port. A third working port (5 or 8 mm) is positioned at the anterior superior iliac spine laterally at a 45-degree offset and 10 cm from the umbilical port. If necessary, a fourth 5-mm port is placed. The fourth port is often helpful in right-sided cases to lift the liver edge and expose the upper pole of the kidney. The table is angled to raise the affected side into a 60-degree flank position. If the da Vinci Surgical System is utilized, the robot is positioned on the ipsilateral side of the patient and angled over the shoulder. The three robotic arms are then engaged to the laparoscopic ports. A 30-degree lens is used in the down position.
abdomen flat, transperitoneal port access is gained using either a Veress needle or with the modified Hasson technique. A camera port (12 mm) is placed at the umbilicus (Fig. 103.1). A second port (5 or 8 mm) is placed superior to the umbilicus in the midline approximately 10 cm from the umbilical port. A third working port (5 or 8 mm) is positioned at the anterior superior iliac spine laterally at a 45-degree offset and 10 cm from the umbilical port. If necessary, a fourth 5-mm port is placed. The fourth port is often helpful in right-sided cases to lift the liver edge and expose the upper pole of the kidney. The table is angled to raise the affected side into a 60-degree flank position. If the da Vinci Surgical System is utilized, the robot is positioned on the ipsilateral side of the patient and angled over the shoulder. The three robotic arms are then engaged to the laparoscopic ports. A 30-degree lens is used in the down position.
 FIGURE 103.1 Port placement for a right-sided laparoscopic partial nephrectomy: camera port (1), right handed laparoscopic or robotic port (2), left handed laparoscopic or robotic port, if performed laparoscopically, a 10 or 12 mm port could be considered if larger laparoscopic instruments are needed for the procedure (3), assistant port (4). |
 FIGURE 103.2 Laparoendoscopic right upper pole partial nephroureterectomy. A: The ureter is clipped and divided in the region of the midureter. B and C: The ureter has been dissected from beneath the main renal pedicle and the upper pole vasculature has been clipped. The hydronephrotic cap is dissected off with the parenchyma minimally divided. D: The ureter is left attached as the remaining wall of the ureter is dissected and ligated at the bladder wall. |
The kidney is exposed by medial reflection of the colon. The ureter from the nonfunctioning moiety (or the single ureter for a complete nephrectomy) is identified and mobilized as distally as the iliac vessels. The nonfunctioning ureter is divided. If there is no VUR, the distal end can be left open. If there is VUR, the distal ureter is ligated with an absorbable stitch. The affected pole is manipulated by using the divided proximal ureter as a handle (Figs. 103.2 and 103.3).
Related posts:
Stay updated, free articles. Join our Telegram channel
Full access? Get Clinical Tree
