- Email: [email protected]
BILATERAL ROBOTIC ASSISTED LAPAROSCOPIC HEMINEPHROURETERECTOMY
0022-5347/04/1716-2394/0 THE JOURNAL OF UROLOGY® Copyright © 2004 by AMERICAN UROLOGICAL ASSOCIATION
Vol. 171, 2394 –2395, June 2004 Printed in U.S.A.
DOI: 10.1097/01.ju.0000124999.30706.ed
BILATERAL ROBOTIC ASSISTED LAPAROSCOPIC HEMINEPHROURETERECTOMY ROBERTO PEDRAZA, LANE PALMER, VANCE MOSS
AND
ISRAEL FRANCO
From the Department of Pediatric Urology, New York Medical College, Valhalla, New York KEY WORDS: ureter, hydronephrosis, cystoscopy
Laparoscopic surgery has an increasingly important role in pediatric urology. It has emerged as an alternative means of performing nephrectomy and heminephroureterectomy in the pediatric population.1 To our knowledge we report the first case of bilateral laparoscopic heminephroureterectomy. CASE REPORT
A 4-year-old girl presented with recurrent urinary tract infections and persistent urinary incontinence. Diagnostic evaluation included ultrasonography (fig. 1) and computerized tomography (fig. 2) which revealed bilateral duplicated collecting systems, left upper pole hydroureteronephrosis and right upper pole hydronephrosis. A renal scan demonstrated bilateral nonfunctioning upper pole moieties and cystoscopy revealed an opening below the bladder neck where 2 ectopic ureters entered. Cystoscopy was performed before the procedure and ureteral catheters were inserted in the 2 lower pole systems. A 6 port transperitoneal approach was used. The patient was placed in the right lateral decubitus position. A pure laparoscopic approach was used to reflect the colon medially, and isolate and dissect the upper pole ureter downward toward the bladder and upward toward the kidney. The lower end of the ureter was clipped and divided. We switched to the daVinci robotic system (Intuitive Surgical, Mountain View, California) to dissect the renal hilum and upper pole vessels, and isolate the upper pole segment. The upper pole segment was excised using the Harmonic scalpel (Ethicon, Somerville, New Jersey) and the argon beam coagulator was used to fulgurate the base of the upper pole segment. The patient was then repositioned to the left lateral decubitus position, and a similar procedure was performed on the right side. A pure laparoscopic method was used initially to reflect the colon medially, perform the Kocher maneuver on the duodenum, and isolate and divide the upper pole ureter. The daVinci robotic system was then used to isolate and excise the upper pole segment, and facilitate fulguration of the base of the upper pole with the argon beam coagulator. There were no intraoperative or postoperative complications. The overall surgical time was 7 hours and 20 minutes. Estimated blood loss was 15 cc. The patient was placed on ketorolac postoperatively and required only 2 doses of supplemental narcotic analgesia. She was discharged home on postoperative day 2 and returned to full activity in 2 weeks.
loss, low morbidity, minimal postoperative discomfort and improved cosmesis. In comparison to the traditional laparoscopic approach, the da Vinci robot was able to facilitate dissection of the renal hilum and upper pole vessels as well as excision of the upper pole segment. In addition, the argon beam coagulator was an effective method of obtaining hemostasis after removal of the upper pole renal parenchyma. For our bilateral procedure the child benefited by performing the surgery through the transperitoneal approach. We were able to avoid complete redraping and repositioning of the patient using this route. Using the bilateral approach, we were able to complete both heminephroureterectomy procedures in a single operative session, saving the patient
FIG. 1. Ultrasound of kidneys demonstrates bilateral duplicated collecting systems and upper pole hydronephrosis.
DISCUSSION
A heminephroureterectomy, a procedure typically performed in children, is technically more difficult than a nephrectomy. Care must be taken not to compromise the blood supply to the remaining ureter or damage the renal parenchyma. Janetschek et al,2 and Yao and Poppas3 each demonstrated that laparoscopic heminephroureterectomy is feasible in children and associated with minimal blood Accepted for publication January 16, 2004.
FIG. 2. Computerized tomography of abdomen reveals bilateral upper pole hydronephrosis. 2394
ROBOTIC ASSISTED LAPAROSCOPIC HEMINEPHROURETERCTOMY
from having to undergo a second surgery. A drawback of implementing the daVinci robot is the time it takes to position the robot onto the operative field. Another potential limitation is the time required to disengage the robotic arms from the trocars if immediate open conversion is necessary. Bilateral laparoscopic heminephroureterectomy is a safe, minimally invasive alternative to traditional open surgery in children, and there is no downside in attempting this procedure.
2395
REFERENCES
1. Prabhakaran, K. and Lingaraj, K.: Laparoscopic nephroureterectomy in children. J Pediatr Surg, 34: 556, 1999 2. Janetschek, G., Seibold, J., Radmayr, C. and Bartsch, G.: Laparoscopic heminephroureterectomy in pediatric patients. J Urol, 158: 1928, 1997 3. Yao, D. and Poppas, D. P.: A clinical series of laparoscopic nephrectomy, nephroureterectomy and heminephroureterectomy in the pediatric population. J Urol, 163: 1531, 2000
Vol. 171, 2394 –2395, June 2004 Printed in U.S.A.
DOI: 10.1097/01.ju.0000124999.30706.ed
BILATERAL ROBOTIC ASSISTED LAPAROSCOPIC HEMINEPHROURETERECTOMY ROBERTO PEDRAZA, LANE PALMER, VANCE MOSS
AND
ISRAEL FRANCO
From the Department of Pediatric Urology, New York Medical College, Valhalla, New York KEY WORDS: ureter, hydronephrosis, cystoscopy
Laparoscopic surgery has an increasingly important role in pediatric urology. It has emerged as an alternative means of performing nephrectomy and heminephroureterectomy in the pediatric population.1 To our knowledge we report the first case of bilateral laparoscopic heminephroureterectomy. CASE REPORT
A 4-year-old girl presented with recurrent urinary tract infections and persistent urinary incontinence. Diagnostic evaluation included ultrasonography (fig. 1) and computerized tomography (fig. 2) which revealed bilateral duplicated collecting systems, left upper pole hydroureteronephrosis and right upper pole hydronephrosis. A renal scan demonstrated bilateral nonfunctioning upper pole moieties and cystoscopy revealed an opening below the bladder neck where 2 ectopic ureters entered. Cystoscopy was performed before the procedure and ureteral catheters were inserted in the 2 lower pole systems. A 6 port transperitoneal approach was used. The patient was placed in the right lateral decubitus position. A pure laparoscopic approach was used to reflect the colon medially, and isolate and dissect the upper pole ureter downward toward the bladder and upward toward the kidney. The lower end of the ureter was clipped and divided. We switched to the daVinci robotic system (Intuitive Surgical, Mountain View, California) to dissect the renal hilum and upper pole vessels, and isolate the upper pole segment. The upper pole segment was excised using the Harmonic scalpel (Ethicon, Somerville, New Jersey) and the argon beam coagulator was used to fulgurate the base of the upper pole segment. The patient was then repositioned to the left lateral decubitus position, and a similar procedure was performed on the right side. A pure laparoscopic method was used initially to reflect the colon medially, perform the Kocher maneuver on the duodenum, and isolate and divide the upper pole ureter. The daVinci robotic system was then used to isolate and excise the upper pole segment, and facilitate fulguration of the base of the upper pole with the argon beam coagulator. There were no intraoperative or postoperative complications. The overall surgical time was 7 hours and 20 minutes. Estimated blood loss was 15 cc. The patient was placed on ketorolac postoperatively and required only 2 doses of supplemental narcotic analgesia. She was discharged home on postoperative day 2 and returned to full activity in 2 weeks.
loss, low morbidity, minimal postoperative discomfort and improved cosmesis. In comparison to the traditional laparoscopic approach, the da Vinci robot was able to facilitate dissection of the renal hilum and upper pole vessels as well as excision of the upper pole segment. In addition, the argon beam coagulator was an effective method of obtaining hemostasis after removal of the upper pole renal parenchyma. For our bilateral procedure the child benefited by performing the surgery through the transperitoneal approach. We were able to avoid complete redraping and repositioning of the patient using this route. Using the bilateral approach, we were able to complete both heminephroureterectomy procedures in a single operative session, saving the patient
FIG. 1. Ultrasound of kidneys demonstrates bilateral duplicated collecting systems and upper pole hydronephrosis.
DISCUSSION
A heminephroureterectomy, a procedure typically performed in children, is technically more difficult than a nephrectomy. Care must be taken not to compromise the blood supply to the remaining ureter or damage the renal parenchyma. Janetschek et al,2 and Yao and Poppas3 each demonstrated that laparoscopic heminephroureterectomy is feasible in children and associated with minimal blood Accepted for publication January 16, 2004.
FIG. 2. Computerized tomography of abdomen reveals bilateral upper pole hydronephrosis. 2394
ROBOTIC ASSISTED LAPAROSCOPIC HEMINEPHROURETERCTOMY
from having to undergo a second surgery. A drawback of implementing the daVinci robot is the time it takes to position the robot onto the operative field. Another potential limitation is the time required to disengage the robotic arms from the trocars if immediate open conversion is necessary. Bilateral laparoscopic heminephroureterectomy is a safe, minimally invasive alternative to traditional open surgery in children, and there is no downside in attempting this procedure.
2395
REFERENCES
1. Prabhakaran, K. and Lingaraj, K.: Laparoscopic nephroureterectomy in children. J Pediatr Surg, 34: 556, 1999 2. Janetschek, G., Seibold, J., Radmayr, C. and Bartsch, G.: Laparoscopic heminephroureterectomy in pediatric patients. J Urol, 158: 1928, 1997 3. Yao, D. and Poppas, D. P.: A clinical series of laparoscopic nephrectomy, nephroureterectomy and heminephroureterectomy in the pediatric population. J Urol, 163: 1531, 2000