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RETROPERITONEAL LAPAROSCOPIC NEPHRECTOMY IN CHILDREN
00226347/98/1603-1142$03.00/0
TIIB JOURNAI,
Vol. 160, 1142-1144, September 1998 Printed in U . S A
OF UROLOGY
Copyright 8 1998 by AMERICAN UROLOGICAL A~~OCIATION, bc.
RETROPERITONEAL LAPAROSCOPIC NEPHRECTOMY IN CHILDREN KATHLEEN C. KOBASHI, DAVID A. CHAMBERLIN, DEEPAK RAJPOOT
AND
ALLAN M. SHANBERG
From the Divisions of Urology and Pediatric Nephrology, University of California-Zrvine, Orange and Tower Urology Institute for Continence, Los Angeles, California
ABSTRACT
Purpose: We report our experience with retroperitoneal laparoscopic nephrectomy and nephroureterectomy in children, and describe our surgical technique. Materials and Methods: Five and 15 children 9 months to 17 years old underwent nephrectomy with cystoscopy plus intravesical ureteral stump fulguration for ureteral ablation and nephrectomy only, respectively. Surgical indications were unilateral multicystic dysplastic kidney in 8 cases (parental preference for surgery), a refluxing, chronic pyelonephritic kidney in 5, renal vascular hypertension in 2, and hydronephrosis and chronic pyelonephritis in 5, including 3 in whom a nephrostomy tube was placed percutaneously before laparoscopic nephrectomy. Access was obtained by a 10 111112. incision made posterior to the anterosuperior iliac spine with dissection into the retroperitoneal space and trochar placement. Two and sometimes 3 additional 5 mm. ports were placed retroperitoneally. Results: Average operative time was 1hour 42 minutes. The most recent cases were performed in less than 1hour and in 3 nephrectomy only required 30 minutes. All but 1procedure were completed laparoscopically. One case was converted to open surgery secondary to obscured visibility due to bleeding. Blood loss in all cases was less than 30 cc (average 5 to 10).A total of 13 children were discharged home immediately postoperatively. Five children underwent concomitant procedures, including contralateral ureteroneocystotomy in 4, circumcision in 1 and cystoscopic fulguration of the ureteral stump in 5. Those who underwent ureteral reimplantation were hospitalized for 48 hours. One patient remained hospitalized for 3 days due to fever of unknown origin and 2 were admitted to the hospital for 23-hour observation. All children returned to full activity within 1 week of surgery. Analgesia consisted of 1 dose of ketorolac, bupivacaine injections at the incisional sites at the completion of the procedure, and acetaminophen postoperatively. Conclusions: As confirmed by parent questionnaire, patient satisfaction was excellent. KET WORDS: kidney, laparoscopy, nephrectomy
Laparoscopic surgery in the pediatric population has continued to gain acceptance since its introduction. Opponents of pediatric laparoscopy cite technical difficulty, increased operative time and potential conversion of retroperitoneal to transperitoneal surgery as disadvantages of the technique. However, as we have noted, the learning curve is steep but with continued experience the laparoscopic technique becomes less technically difficult and operative time decreases. Much of the early literature derives from Europe, where initial experience with the technique was acquired.'S2 Studies have evaluated open versus laparoscopic surgery, the transperitoneal versus retroperitoneal approach, operative and recovery time, and complications. We present our experience with retroperitoneal cases to support and demonstrate the role of laparoscopy in pediatric urological surgery. METHODS
Between 1993 and 1997,14boys and 6 girls 9 months to 17 years old (5 or 25% younger than 1 year) underwent retroperitoneal laparoscopic nephrectomy performed by one of us (A. M. SJ, including nephrectomy only in 15 and nephroureterectomy with cystoscopy plus intravesical ureteral stump fulguration in 5. Indications for the procedure were unilateral multicystic dysplastic kidney in 8 cases (parental preference for surgery), a refluxing, chronic pyelonephritic kidney in 5, renal vascular hypertension in 2, and hydronephrosis and chronic pyelonephritis in 5 (see table). Initially the patient is placed in the flank position with the
Patient characteristics No. pts. 20 9 Mos.-l7 yrs. Age range No. boydNo. girls 14/6 No. pts. with: Reflux nephropathy 5 Multicystic dysplatic kidney a Hydronephrosis with pyelonephritis 5 Urinary tract infection 10 Hypertension 2 Av. operative time 1 HI. 42 mins.* No. OUtDb. 17 * Including concomitant contralateral ureteroneocystotomy, circumcisionor cystoscopic Mguration of the ureteral stump.
affected side exposed (fig. 1).Access is obtained by a 10 mm. incision made posterior to the anterosuperior iliac spine with dissection into the retroperitoneal space. The space is then carefully developed with blunt finger dissection, followed by introduction into the space of a rubber catheter with an excised glove finger securely attached to its distal end (fig. 2). The balloon is filled with 200 to 400 cc cold saline, and it remains in place for 5 minutes, which aids in the development of the retroperitoneal space (fig. 3). Cold saline is essential to prevent balloon rupture. A Hasson trochar is placed, pneumoretroperitoneum is created and 2 additional 5 mm. ports are placed retroperitoneally. In 2 children in this series a third port was placed. "he first visual landmark is the psoas muscle, which is followed superiorly to the kidney. Using a combination of
1142
RETROPERITONEAL LAPAROSCOPIC NEPHRECTOMY
FIG. 1. Patient lateral with trochar sites marked
1143
year a combined retroperitoneal and transperitoneal approach was used secondary to inadvertent peritoneal tearing. Immediately after the procedure 13 children were discharged home on an outpatient basis, 2 were observed for 23 hours and 1 remained hospitalized for 3 days secondary to fever of unknown origin. All patients returned to normal activity within 1 week postoperatively. Four children who underwent concomitant contralateral ureteroneocystotomy were hospitalized for 48 hours. Each child received 1 dose of ketorolac intravenously at the conclusion of surgery and none who underwent nephrectomy only required more than acetaminophen postoperatively. Patient satisfaction was excellent, as confirmed by parent questionnaire. Of the 2 patients with hypertension preoperatively medications were withdrawn in 1within 1week of surgery. In the other patient mild hypertension required medication but the condition was far less severe and easier to control than it had been preoperatively. None of the patients had subsequent problems with urinary tract infection. However, in 1 child with minimal reflux up the ureteral stump despite Bugbee fulguration of the stump and ureteral orifice intraoperatively a repeat procedure was performed 6 months later to fulgurate the remaining stump cystoscopically. There were no further problems. DISCUSSION
FIG. 2. Excised glove finger is secured to end of Robinson catheter.
sharp and blunt dissection the scant retroperitoneal fat is dissected from the kidney. The kidney is then freed at all aspects, and the ureter is exposed, doubly clipped and divided. The kidney hilum is exposed to reveal the vessels. Each renal artery and vein are ligated with 4 clips and divided, leaving 3 clips on the patent side (fig. 4).Any remaining attachments are fulgurated with electrocautery until the kidney is completely freed. Usually the kidney may then be brought through a trochar incisional site with extension of the incision as necessary. In cases of multicystic dysplastic kidneys cysts may also be decompressed to facilitate passage of the specimen through the incision. When it is too large, the kidney is placed in a collection bag and excised into smaller pieces or morcellation is done, although this was not necessary in our series. The surgical field is examined carefully to ensure hemostasis and the trochars are then removed under direct vision. The muscle is closed with figure-of-8 polyglactin stitches and the skin is reapproximated with subcuticular 4-zero polyglactin stitches. Bupivacaine (%%) is injected into the incisions and 1dose of ketorolac is given at the completion of the procedure. In 3 patients cystoscopic fulguration of the ureteral stump with a Bugbee electrode was done during the same anesthesia. RESULTS
The 20 patients were followed for 6 months to 4 years. Average operating time for nephrectomy was 1hour 42 minutes, including simultaneous contralateral ureteral reimplantation, circumcision or cystoscopic ureteral fulguration. Average blood loss was 5 to 10 cc and less than 30 in all cases. In 1 case bleeding obscured surgeon vision during the laparoscopic procedure, necessitating immediate conversion to a n open incision. A vena caval laceration was repaired and transfusion was not required. In 3 patients younger than 1
Laparoscopic surgery is feasible in the pediatric patient and it provides many advantages over standard open techniques, including more rapid recovery, improved cosmesis, less postoperative pain and consequently a lower analgesic requirement. The often cited disadvantages include technical difficulty, increased operative time and conversion of retroperitoneal open surgery to transperitoneal surgery, none of which has been a major problem in our experience. As surgeons continue to gain experience, surgery becomes less technically challenging and operative time continues to decrease. In our most recent cases operative time was approximately 30 minutes. Ehrlich et a1 stated that the incisions necessary for laparoscopy are not much shorter than those needed for open nephre~tomy.~ In our experience 10 mm. plus 2 , 5 mm. ports yield an incision approximately 1 inch long. Open surgery through a 1-inch incision in infants may be more difficult and dangerous than laparoscopic surgery secondary to difficult exposure, particularly at the hilum. We attempted to perform open nephrectomy in a child through a 1-inch incision and were unable to gain adequate exposure to complete the procedure without significantly extending the incision. Laparoscopic surgery definitely provides better visualization. In our experience the retroperitoneal approach in children is easier due to the paucity of fat, which allows easy kidney localization and requires less operative time than the transperitoneal approach. A review of the literature indicates the growing popularity of laparoscopic nephrectomy in the pediatric population. 0 t h ers have evaluated complications as well as operative and recovery times, and compared transperitoneal versus retroperitoneal t e c h n i q ~ e s . ' . ~ *In ~ - 1996 ~ Valla et a1 reported their experience with 18 patients 3 months to 14 years old.2 Mean operative time was 120 minutes. There was only 1 conversion to open surgery and no other complications. I n 1993 Figenshau et a1 described the initial laparoscopic nephroureterectomy with excision of a bladder cuff in a 6-year-old girl with reflux nephropathy and recurrent urinary tract infections despite antibiotic^.^ There were no complications, total operative time was 5 hours 35 minutes and estimated blood loss was 50 cc. Ehrlich et a1 also reported their experience with laparoscopic renal surgery not limited to nephre~tomy.~ Similar to our experience, hospital stay was less than for open procedures (23 versus 36 hours), patients
1144
RETROPERITONEAL LAPAROSCOPIC NEPHRECTOMY
FIG. 3. Balloon is filled with cold saline to develop retroperitoneal space was not so i n our case. Diamond et a1 described their experience with t h e retroperitoneal technique in 3 patient^.^ Operative time ranged from 3 to 5 hours a n d the patients returned to normal activity within 7 days. CONCLUSIONS
FIG.4. Clips in situ on renal vein returned to normal activity promptly (2 days) and preoperative hypertension resolved postoperatively in 1. This surgery may be performed via a retroperitoneal or transperitoneal approach. Emmert et al described their transperitoneal approach for multicystic dysplastic kidney." With the exception of the approach, and trochar sizes and placement their general technique is similar to ours. A Cook Lapsac bag was used to envelop the specimen before removal and no morcellation was necessary. We prefer to use the retroperitoneal approach when possible, although i t tends to be more difficult a t ages less t h a n 1 year. Almost invariably in these patients peritoneal entry was achieved secondary to inadvertent peritoneal tearing during the creation of the pneumoretroperitoneum. However, the technique was generally not difficult in t h e older patients. We believe t h a t at ages less t h a n l year t h e peritoneum is extremely thin and susceptible to tearing. While the complication may be avoided by limiting retroperitoneal fluid insumation volume to 150 cc. this would result in less optimal exposure. The approach provides the advantage of easy visualization of the renal pedicle, lack of interference secondary to intraperitoneal structures and adhesions, and avoidance of postoperative adhesion formation. Theoretically recovery is also more rapid with this technique, although this
Laparoscopy i n pediatric urology i s quickly gaining popularity and in experienced hands it is safe in this population. As surgeons become more experienced with this technique, more complex procedures a r e being performed. Laparoscopic nephrectomy for nonfunctioning kidneys with recurrent infection or secondary hypertension is emerging as a reasonable alternative to open surgery. The advantages of this technique are improved cosmesis, shorter hospital stay, decreased analgesic requirements a n d a significantly shorter recovery period. The previously considered disadvantages of this surgery (operative time and technical difficulty) have become less of a concern as we gain experience with this procedure. REFERENCES
1. Doublet, J. D., Barreto, H. S., Degremont, A. C., Gattengo, B.
and Thibault, P.: Retroperitoneal nephrectomy comparison of laparoscopy with open surgery. World J. Urol., 20 713, 1996. 2. Valla, J. S.,Guilloneau,B., Montupet, P., Geiss, S., Steyaert, H., el Ghoneimi, A., Jordana, F. and Volpe, P.: Retroperitoneal laparoscopicnephrectomy in children: preliminary report of 18 cases. Eur. Urol., 3 0 490,1996. 3. Ehrlich, R.M., Gershman, A. and Fuchs, G.: Laparoscopic renal surgery in children. J. Urol., 151: 735, 1994. 4. Diamond, D. A,, Price, H. M., McDougall, E. M. and Bloom, D. A.: Retroperitoneal laparoscopic nephrectomy in children. J. Urol., 153: 1966,1995. 5. Gill, I. S.,Delworth, M. G . and Munch, L. C.: Laparoscopic retroperitoneal partial nephrectomy. J. Urol., 152 1539,1994. 6. Ono, Y.,Katoh, N., Kinukawa, T., Matsuura, 0. and Ohshma, S.: Laparoscopic nephrectomy via the retroperitoneal approach. J . Urol., 156 110,1996. 7. Figenshau, R. S.,Clayman, R. V., Kerbl, K., McDougall, E. M. and Colberg, J. W.: Laparoscopic nephroureterectomy in the child initial case report. J . Urol., 151: 740,1994. 8. Emmert, G.K., Eubanks, S. and King, L.: Improved technique of laparoscopic nephrectomy for multicystic dysplastic kidney. Urology, 44.422, 1994.
TIIB JOURNAI,
Vol. 160, 1142-1144, September 1998 Printed in U . S A
OF UROLOGY
Copyright 8 1998 by AMERICAN UROLOGICAL A~~OCIATION, bc.
RETROPERITONEAL LAPAROSCOPIC NEPHRECTOMY IN CHILDREN KATHLEEN C. KOBASHI, DAVID A. CHAMBERLIN, DEEPAK RAJPOOT
AND
ALLAN M. SHANBERG
From the Divisions of Urology and Pediatric Nephrology, University of California-Zrvine, Orange and Tower Urology Institute for Continence, Los Angeles, California
ABSTRACT
Purpose: We report our experience with retroperitoneal laparoscopic nephrectomy and nephroureterectomy in children, and describe our surgical technique. Materials and Methods: Five and 15 children 9 months to 17 years old underwent nephrectomy with cystoscopy plus intravesical ureteral stump fulguration for ureteral ablation and nephrectomy only, respectively. Surgical indications were unilateral multicystic dysplastic kidney in 8 cases (parental preference for surgery), a refluxing, chronic pyelonephritic kidney in 5, renal vascular hypertension in 2, and hydronephrosis and chronic pyelonephritis in 5, including 3 in whom a nephrostomy tube was placed percutaneously before laparoscopic nephrectomy. Access was obtained by a 10 111112. incision made posterior to the anterosuperior iliac spine with dissection into the retroperitoneal space and trochar placement. Two and sometimes 3 additional 5 mm. ports were placed retroperitoneally. Results: Average operative time was 1hour 42 minutes. The most recent cases were performed in less than 1hour and in 3 nephrectomy only required 30 minutes. All but 1procedure were completed laparoscopically. One case was converted to open surgery secondary to obscured visibility due to bleeding. Blood loss in all cases was less than 30 cc (average 5 to 10).A total of 13 children were discharged home immediately postoperatively. Five children underwent concomitant procedures, including contralateral ureteroneocystotomy in 4, circumcision in 1 and cystoscopic fulguration of the ureteral stump in 5. Those who underwent ureteral reimplantation were hospitalized for 48 hours. One patient remained hospitalized for 3 days due to fever of unknown origin and 2 were admitted to the hospital for 23-hour observation. All children returned to full activity within 1 week of surgery. Analgesia consisted of 1 dose of ketorolac, bupivacaine injections at the incisional sites at the completion of the procedure, and acetaminophen postoperatively. Conclusions: As confirmed by parent questionnaire, patient satisfaction was excellent. KET WORDS: kidney, laparoscopy, nephrectomy
Laparoscopic surgery in the pediatric population has continued to gain acceptance since its introduction. Opponents of pediatric laparoscopy cite technical difficulty, increased operative time and potential conversion of retroperitoneal to transperitoneal surgery as disadvantages of the technique. However, as we have noted, the learning curve is steep but with continued experience the laparoscopic technique becomes less technically difficult and operative time decreases. Much of the early literature derives from Europe, where initial experience with the technique was acquired.'S2 Studies have evaluated open versus laparoscopic surgery, the transperitoneal versus retroperitoneal approach, operative and recovery time, and complications. We present our experience with retroperitoneal cases to support and demonstrate the role of laparoscopy in pediatric urological surgery. METHODS
Between 1993 and 1997,14boys and 6 girls 9 months to 17 years old (5 or 25% younger than 1 year) underwent retroperitoneal laparoscopic nephrectomy performed by one of us (A. M. SJ, including nephrectomy only in 15 and nephroureterectomy with cystoscopy plus intravesical ureteral stump fulguration in 5. Indications for the procedure were unilateral multicystic dysplastic kidney in 8 cases (parental preference for surgery), a refluxing, chronic pyelonephritic kidney in 5, renal vascular hypertension in 2, and hydronephrosis and chronic pyelonephritis in 5 (see table). Initially the patient is placed in the flank position with the
Patient characteristics No. pts. 20 9 Mos.-l7 yrs. Age range No. boydNo. girls 14/6 No. pts. with: Reflux nephropathy 5 Multicystic dysplatic kidney a Hydronephrosis with pyelonephritis 5 Urinary tract infection 10 Hypertension 2 Av. operative time 1 HI. 42 mins.* No. OUtDb. 17 * Including concomitant contralateral ureteroneocystotomy, circumcisionor cystoscopic Mguration of the ureteral stump.
affected side exposed (fig. 1).Access is obtained by a 10 mm. incision made posterior to the anterosuperior iliac spine with dissection into the retroperitoneal space. The space is then carefully developed with blunt finger dissection, followed by introduction into the space of a rubber catheter with an excised glove finger securely attached to its distal end (fig. 2). The balloon is filled with 200 to 400 cc cold saline, and it remains in place for 5 minutes, which aids in the development of the retroperitoneal space (fig. 3). Cold saline is essential to prevent balloon rupture. A Hasson trochar is placed, pneumoretroperitoneum is created and 2 additional 5 mm. ports are placed retroperitoneally. In 2 children in this series a third port was placed. "he first visual landmark is the psoas muscle, which is followed superiorly to the kidney. Using a combination of
1142
RETROPERITONEAL LAPAROSCOPIC NEPHRECTOMY
FIG. 1. Patient lateral with trochar sites marked
1143
year a combined retroperitoneal and transperitoneal approach was used secondary to inadvertent peritoneal tearing. Immediately after the procedure 13 children were discharged home on an outpatient basis, 2 were observed for 23 hours and 1 remained hospitalized for 3 days secondary to fever of unknown origin. All patients returned to normal activity within 1 week postoperatively. Four children who underwent concomitant contralateral ureteroneocystotomy were hospitalized for 48 hours. Each child received 1 dose of ketorolac intravenously at the conclusion of surgery and none who underwent nephrectomy only required more than acetaminophen postoperatively. Patient satisfaction was excellent, as confirmed by parent questionnaire. Of the 2 patients with hypertension preoperatively medications were withdrawn in 1within 1week of surgery. In the other patient mild hypertension required medication but the condition was far less severe and easier to control than it had been preoperatively. None of the patients had subsequent problems with urinary tract infection. However, in 1 child with minimal reflux up the ureteral stump despite Bugbee fulguration of the stump and ureteral orifice intraoperatively a repeat procedure was performed 6 months later to fulgurate the remaining stump cystoscopically. There were no further problems. DISCUSSION
FIG. 2. Excised glove finger is secured to end of Robinson catheter.
sharp and blunt dissection the scant retroperitoneal fat is dissected from the kidney. The kidney is then freed at all aspects, and the ureter is exposed, doubly clipped and divided. The kidney hilum is exposed to reveal the vessels. Each renal artery and vein are ligated with 4 clips and divided, leaving 3 clips on the patent side (fig. 4).Any remaining attachments are fulgurated with electrocautery until the kidney is completely freed. Usually the kidney may then be brought through a trochar incisional site with extension of the incision as necessary. In cases of multicystic dysplastic kidneys cysts may also be decompressed to facilitate passage of the specimen through the incision. When it is too large, the kidney is placed in a collection bag and excised into smaller pieces or morcellation is done, although this was not necessary in our series. The surgical field is examined carefully to ensure hemostasis and the trochars are then removed under direct vision. The muscle is closed with figure-of-8 polyglactin stitches and the skin is reapproximated with subcuticular 4-zero polyglactin stitches. Bupivacaine (%%) is injected into the incisions and 1dose of ketorolac is given at the completion of the procedure. In 3 patients cystoscopic fulguration of the ureteral stump with a Bugbee electrode was done during the same anesthesia. RESULTS
The 20 patients were followed for 6 months to 4 years. Average operating time for nephrectomy was 1hour 42 minutes, including simultaneous contralateral ureteral reimplantation, circumcision or cystoscopic ureteral fulguration. Average blood loss was 5 to 10 cc and less than 30 in all cases. In 1 case bleeding obscured surgeon vision during the laparoscopic procedure, necessitating immediate conversion to a n open incision. A vena caval laceration was repaired and transfusion was not required. In 3 patients younger than 1
Laparoscopic surgery is feasible in the pediatric patient and it provides many advantages over standard open techniques, including more rapid recovery, improved cosmesis, less postoperative pain and consequently a lower analgesic requirement. The often cited disadvantages include technical difficulty, increased operative time and conversion of retroperitoneal open surgery to transperitoneal surgery, none of which has been a major problem in our experience. As surgeons continue to gain experience, surgery becomes less technically challenging and operative time continues to decrease. In our most recent cases operative time was approximately 30 minutes. Ehrlich et a1 stated that the incisions necessary for laparoscopy are not much shorter than those needed for open nephre~tomy.~ In our experience 10 mm. plus 2 , 5 mm. ports yield an incision approximately 1 inch long. Open surgery through a 1-inch incision in infants may be more difficult and dangerous than laparoscopic surgery secondary to difficult exposure, particularly at the hilum. We attempted to perform open nephrectomy in a child through a 1-inch incision and were unable to gain adequate exposure to complete the procedure without significantly extending the incision. Laparoscopic surgery definitely provides better visualization. In our experience the retroperitoneal approach in children is easier due to the paucity of fat, which allows easy kidney localization and requires less operative time than the transperitoneal approach. A review of the literature indicates the growing popularity of laparoscopic nephrectomy in the pediatric population. 0 t h ers have evaluated complications as well as operative and recovery times, and compared transperitoneal versus retroperitoneal t e c h n i q ~ e s . ' . ~ *In ~ - 1996 ~ Valla et a1 reported their experience with 18 patients 3 months to 14 years old.2 Mean operative time was 120 minutes. There was only 1 conversion to open surgery and no other complications. I n 1993 Figenshau et a1 described the initial laparoscopic nephroureterectomy with excision of a bladder cuff in a 6-year-old girl with reflux nephropathy and recurrent urinary tract infections despite antibiotic^.^ There were no complications, total operative time was 5 hours 35 minutes and estimated blood loss was 50 cc. Ehrlich et a1 also reported their experience with laparoscopic renal surgery not limited to nephre~tomy.~ Similar to our experience, hospital stay was less than for open procedures (23 versus 36 hours), patients
1144
RETROPERITONEAL LAPAROSCOPIC NEPHRECTOMY
FIG. 3. Balloon is filled with cold saline to develop retroperitoneal space was not so i n our case. Diamond et a1 described their experience with t h e retroperitoneal technique in 3 patient^.^ Operative time ranged from 3 to 5 hours a n d the patients returned to normal activity within 7 days. CONCLUSIONS
FIG.4. Clips in situ on renal vein returned to normal activity promptly (2 days) and preoperative hypertension resolved postoperatively in 1. This surgery may be performed via a retroperitoneal or transperitoneal approach. Emmert et al described their transperitoneal approach for multicystic dysplastic kidney." With the exception of the approach, and trochar sizes and placement their general technique is similar to ours. A Cook Lapsac bag was used to envelop the specimen before removal and no morcellation was necessary. We prefer to use the retroperitoneal approach when possible, although i t tends to be more difficult a t ages less t h a n 1 year. Almost invariably in these patients peritoneal entry was achieved secondary to inadvertent peritoneal tearing during the creation of the pneumoretroperitoneum. However, the technique was generally not difficult in t h e older patients. We believe t h a t at ages less t h a n l year t h e peritoneum is extremely thin and susceptible to tearing. While the complication may be avoided by limiting retroperitoneal fluid insumation volume to 150 cc. this would result in less optimal exposure. The approach provides the advantage of easy visualization of the renal pedicle, lack of interference secondary to intraperitoneal structures and adhesions, and avoidance of postoperative adhesion formation. Theoretically recovery is also more rapid with this technique, although this
Laparoscopy i n pediatric urology i s quickly gaining popularity and in experienced hands it is safe in this population. As surgeons become more experienced with this technique, more complex procedures a r e being performed. Laparoscopic nephrectomy for nonfunctioning kidneys with recurrent infection or secondary hypertension is emerging as a reasonable alternative to open surgery. The advantages of this technique are improved cosmesis, shorter hospital stay, decreased analgesic requirements a n d a significantly shorter recovery period. The previously considered disadvantages of this surgery (operative time and technical difficulty) have become less of a concern as we gain experience with this procedure. REFERENCES
1. Doublet, J. D., Barreto, H. S., Degremont, A. C., Gattengo, B.
and Thibault, P.: Retroperitoneal nephrectomy comparison of laparoscopy with open surgery. World J. Urol., 20 713, 1996. 2. Valla, J. S.,Guilloneau,B., Montupet, P., Geiss, S., Steyaert, H., el Ghoneimi, A., Jordana, F. and Volpe, P.: Retroperitoneal laparoscopicnephrectomy in children: preliminary report of 18 cases. Eur. Urol., 3 0 490,1996. 3. Ehrlich, R.M., Gershman, A. and Fuchs, G.: Laparoscopic renal surgery in children. J. Urol., 151: 735, 1994. 4. Diamond, D. A,, Price, H. M., McDougall, E. M. and Bloom, D. A.: Retroperitoneal laparoscopic nephrectomy in children. J. Urol., 153: 1966,1995. 5. Gill, I. S.,Delworth, M. G . and Munch, L. C.: Laparoscopic retroperitoneal partial nephrectomy. J. Urol., 152 1539,1994. 6. Ono, Y.,Katoh, N., Kinukawa, T., Matsuura, 0. and Ohshma, S.: Laparoscopic nephrectomy via the retroperitoneal approach. J . Urol., 156 110,1996. 7. Figenshau, R. S.,Clayman, R. V., Kerbl, K., McDougall, E. M. and Colberg, J. W.: Laparoscopic nephroureterectomy in the child initial case report. J . Urol., 151: 740,1994. 8. Emmert, G.K., Eubanks, S. and King, L.: Improved technique of laparoscopic nephrectomy for multicystic dysplastic kidney. Urology, 44.422, 1994.