LAPAROSCOPIC HEMINEPHROURETERECTOMY IN PEDIATRIC PATIENTS

v01.158, 1928-1930. November 1997 Printed in USA.

LAPAROSCOPIC HEMINEPHROURETERECTOMY IN PEDIATRIC PATIENTS G m R JANETSCHEK, JORG SEIBOLD, CHRISTIAN FtADMAYR AND GEORG BARTSCH From the Department of Urology, University of Innsbruck, Innsbruck, Austria

ABSTRACT

Purpose: An increasing number of operative procedures in pediatric urology can be performed by laparoscopy. We report our experience with laparoscopic heminephroureterectorny, which is a typical operation in pediatric patients. Materials and Methods: Laparoscopic heminephroureterectomy was performed in 14 consecutive children. In 12 cases 7 upper renal poles were removed for ectopic refluxing megaureter and obstructive ureterocele in 5 and 2, respectively. In 5 children lower poles were destroyed by reflux nephropathy. In 2 children laparoscopic upper pole heminephroureterectomy for obstructive ureterocele was combined with a Pfannenstiel incision for reimplantation of the refluxing lower pole ureter. b s d t s : 4 1 operations were completed as planned. Operative time was 180 to 330 minutes (mean 222) in group 1 and 345 to 510 (mean 427) in group 2. Blood loss was minimal (10 to 30 ml.) and there were no intraoperative or postoperative complications. Mean postoperative hospital stay in groups 1 and 2 was 4.4 and 7.5 days, respectively. Conclusions: Laparoscopic heminephroureterectomy in children is feasible and associated with minimal blood loss, low morbidity and a low complication rate. The disadvantage is the long operative time. This technically demanding procedure should be performed only at specialized centers. KEYWORDS:laparoscopy, kidney

In the last few years the indications for laparoscopic surgery have increased in adult and pediatric urology.1-3 Previous studies have shown that laparoscopic nephrectomy and nephroureterectomy are more easily performed in infants than in a d ~ l t s . Heminephroureterectomy, ~-~ which is a typical procedure in pediatric urology, is technically more demanding than nephrectomy. The remaining part of the duplex kidney must not be damaged and bleeding is to be avoided. On the other hand, the blood supply to the remaining ureter should not be compromised by separation of the ureters. We report our experience with 14 consecutive cases of laparoscopic heminephroureterectomy. MATERIALS AND METHODS

From August 1993 to September 1996 laparoscopic heminephroureterectomy was performed in 14 consecutive children, including 7 girls and 7 boys 7 months to 14 years old (mean age 5.4). In 12 children (group 1) complete heminephroureterectomy was performed by laparoscopy and no additional open surgical procedure was required. Upper pole heminephroureterectomy was done for ectopic refluxing megaureter and ectopic obstructive megaureter in 5 and 2 group 1 children, respectively. In another 5 children the lower poles had been destroyed by reflux nephropathy. In 2 children (group 2) laparoscopic upper pole heminephroureterectomy for a nonfunctioning upper pole secondary to an obstructive ureterocele was combined with a Pfannenstiel incision for ureterocelectomy and ureteral reimplantation of the lower pole system. The indication for additional open surgery was reflux in the lower pole system. For laparoscopic heminephroureterectomy the patient is positioned to allow rotation from the supine to the lateral decubitus position with the ipsilateral side elevated approximately 30 degrees. The table is flexed as for a flank incision. Accepted for publication March 7. 1997.

Body pressure points are carefully protected with pads. A urethral catheter is placed preoperatively. Ureteral stenting is not required for identification of the ureter. Since transurethral circumcision of the ureteral orifice is not feasible in a duplicated system, neither antegrade nor retrograde ureteral stripping is performed. A 4-port transperitoneal approach is used. The trocars used in ureterectomy are the same as in heminephrectomy and no additional trocars are required for the second procedure. To introduce the laparoscope with the camera a 10 111111. Hasson cannula is placed in the umbilical region via minilaparotomy. In children an intraperitoneal pressure of 10 to 12 mm. Hg is sufficient. Two additional 10 mm. working ports for the surgeon are placed under direct vision pararectally cranial and caudal to the umbilicus. For the assistant a trocar is placed laterally in the lower abdomen. In a few early cases an additional trocar was placed on the right side for retraction of the liver but we have learned to perform the procedure with 4 trocars on the right side. After incising the line of Toldt the colon is mobilized medially. In the laparoscopic transperitoneal approach the distal ureter runs directly beneath the parietal peritoneum and enters the small pelvic area inferior to its crossing with the common iliac artery, which is an important landmark. The crossing of the ureter with the medial umbilical ligament is another landmark, and the ureter can be readily identified by incising the parietal peritoneum in this area. In girls the topographical anatomy is more difficult due to the relationship among the ureter, ovarian vein, broad ligament and uterus. Following incision of the parietal peritoneum and dissection of the duplex ureters the latter can be separated. If 1ureter is dilated, it can easily be identified. Otherwise both ureters must be followed up to the pelvic region for definite identification. Care must be taken to preserve the periureteral tissue supplying the healthy ureter. Before hemine-

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phrectomy the ureter to be excised is dissected at the level of the bladder. Absorbable clips are used for ligating the distal stump, since metal clips are not used in children. Ureterectomy is performed first because it is associated with a low risk of conversion to open surgery. No additional incision is necessary for ureterectomy if any complications necessitating conversion occur during heminephrectomy. To dissect the upper pole and its supplying vessels the dissected ureter must be pulled through beneath the renal vessels, which is not necessary for lower pole ablation. The branches of the renal vein and artery supplying the pole to be ablated are ligated separately with absorbable endoscopic clips (part A of figure). Again no metal clips or staplers are used. Subsequently the border between the upper and lower pole may be readily identified and ablation is performed by bipolar coagulation (part B of figure). For hemostasis bipolar coagulation and the argon beam coagulator are used. However, our experience has shown that bipolar coagulation is superior to the argon beam coagulator in this setting. Hence in our more recent cases we have not used the argon beam coagulator. The cut surface is additionally sealed with fibrin glue and hemostatic material (oxidized regenerated cellulose). Gerota’s fascia is then sutured over this area. This technique guarantees minimal blood loss. The resected pole and ureter are placed in a n entrapment sack and removed through the minilaparotomy. All 5 and 10 mm. port sites are carefully closed. Closure of the abdominal fascia is essential to preclude bowel herniation. The skin is closed with an intracuticular running suture and sterile strips.

and lower abdominal surgical incisions are necessary. In contrast, laparoscopic ureterectomy can be performed using the same trocars as in heminephrectomy, so that no additional trocars are required. Usually 4 trocars suffice for complete heminephroureterectomy. In only a few cases an additional 5 mm. trocar was placed for retraction of the liver on the right side. The double benefit of this procedure is that the patient can be spared 2 surgical incisions and laparoscopy can be combined with open surgery, if necessary, as in both children who underwent excision of a ureterocele and reimplantation of the remaining refluxing lower pole ureter by open surgery. In these cases the preceding laparoscopic dissection of both ureters proved to be helpful for open surgery, since only a relatively small Pfannenstiel incision instead of a lower abdominal incision was required, minimizing operative trauma. Intraoperatively laparoscopy provides an excellent overview of the anatomical structures and magnification allows exact pole ablation along the anatomical border. Gentle handling of the remaining kidney and ureter minimizes tissue trauma. There is only a minor risk of uncontrollable bleeding during laparoscopic heminephrectomy because the vessels supplying the pole to be ablated are ligated and transected before pole ablation, for which bipolar coagulation, the argon beam coagulator and fibrin glue are used. In the present series no uncontrollable bleeding occurred and it was not necessary to convert the procedure to open surgery. Even if conversion during pole ablation were necessary, the laparoscopic approach would preclude making an incision in the lower abdomen, since laparoscopic ureterectomy is performed first. Due to gentle tissue handling and visual magRESULTS nification there was minimal intraoperative blood loss in all Mean operative time was 222 minutes (range 180 to 330)in patients. Intraoperative and postoperative morbidity was low group 1 and 427 minutes (range 345 to 510)in group 2. Due and there were no postoperative complications. to minimal operative trauma blood loss was low (10 to 30 The mean 4.4-day hospital stay may appear long by Amerd.). There were no intraoperative complications. Oral fluid ican standards but it is brief in Europe, where hospitalization intake and ambulation were resumed on postoperative day 1. for open surgery for the same indication is more than twice as In group 1 postoperative hospital stay was 3 to 6 days (mean long. In contrast, in the United States the postoperative 4.4) and in group 2 it was 7 to 8 days. Recovery was rapid and hospital stay for patients undergoing laparoscopic hemithere were no postoperative complications. nephroureterectomy would probably be 1 or 2 days, which seems reasonable. Our patients resumed oral fluid intake DISCUSSION and ambulation within 24 hours. The disadvantage of laparoscopy is operative time, which is In recent years laparoscopic techniques have been increasingly accepted in adult urological surgery.1~~ Based on this clearly longer than that of open surgery. While operative experience laparoscopic techniques have been extended to time may be influenced by the learning curve, we do not pediatric urology,13 not only for the diagnosis of cryptorchid believe that it will ever match that of open surgery. Long testicles8. 9 but also for more complex procedures, such as operative time is associated with increased costs, which to gonadectomy, orchiopexy, hydrocele repair,lO nephre~torny,~some extent may be compensated for by shorter postoperanephroureteretomp and heminephroureterectomy. l1 We re- tive hospitalization. In terms of cost, early return to working port our experience with pediatric heminephroureterectomy activities is another argument in favor of laparoscopy. However, this argument is not valid in children. Therefore, lapaperformed by laparoscopy. For complete open surgical heminephroureterectomy flank roscopic heminephroureterectomy may be more expensive

Laparoscopic heminephroureterectomyof upper renal pole on right side. A, a h r dissection of upper pole ureter upper pole vessels are bated. 4, upper pole vessels. B, aRer dissection of upper pole vessels pole ablation is performed by gentle traction on ureter. 4, absorbable &ps placed on ligated upper pole vessels. I , liver. 2, upper pole. 3, megaureter. 5, lower pole. 6, lower pole vessels.

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than open surgery and this disadvantage must be weighed against the advantages. CONCLUSION

Laparoscopic heminephroureterectomy is feasible, a n d associated with low morbidity and a low intraopenttive and postoperative complication rate. Its disadvantage is the long operative time. By using the same trocars for heminephrectomy a n d ureterectomy the patient is spared the 2 incisions necessary for open surgery. There i s a double benefit for the patient in this respect. Furthermore, lapamscopy in combination with open surgery provides excellent cosmetic results with minimal morbidity. Yet in infants laparoscopic heminephroureterectomy is a demanding procedure, which should be performed only at specialized centers.

G.H.,&bey, E. L. and Winslow. B. H.: LapEUoendoscopic surgical management of the abdominalltransinguinal undeecended testicle. J . Endourol., 6: 159,1992. 10. Janetschek, G.,Reissigl, A. and Bartsch, G.: Laparoscopic repair of pediatric h y h l e s . J. Endoml., 8: 415,1994. 11. Jordan, G . H.and Winslow, B. H.:Laparoendoecopic upper pole partial nephrectomy with ureterectomy. J. Urol., 150: 9-40, 1993. 9. Jordan,

EDITORIAL COMMENT

The authors are to be commended for successful laparoscopic heminephroureterectomy in 14 d a t r i c patients 7 months to 14 years old. They emphasize 2 advantages of this approach, decreased morbidity is not quantitated and total ureterectomy may be performed without a second incision. The disadvantages of laparoscopic heminephroureterettomy are conversion of a retroperitoneal procedure to a transperitoneal one and longer operative time (3 to 5% hours). To assess truly the benefit of the laparoscopic approach REFERENCES versus standard open surgery a randomized prospective study com1. Clayman, R. V., Kavoussi, L. R., Long, S. R., Dierks, S. M., paring results, morbidity and cost within individual health care Meretyk. S. and Soper, N. J.: Laparoscopic nephrectomy: ini- systems should be performed. tial report of pelviscopic organ ablation in the pig. J. EnDavid A. Diamond dourol., 4247,1990. Division of Urology 2. Ehrlich, R., Gershman, A., F’uchs, G. and Mee, S.:Expanding Children’s Hospital horizons in pediatric laparoscopy. J. Urol., part 2, 4 26lA, Boston, Massachusetts abstract 190, 1993. 3. Fuchs, G. J., Gershman, A. and Ehrlich, R. M.: Laparoscopic REPLY BY AUTHORS surgery in pediatric patients. In: Laparoscopic Surgery in Urology. Edited by G. Janetschek, J. Rassweiler and D. P. We compared the results of the last 8 open surgical hemiGriffith. New York: Thieme, chapt. 10,pp. 106-122, 1996. nephroureteredomies performed a t our institution with the present 4. Ehrlich, R.M.,Gershman, A. and Fuchs, G.: Laparoscopic renal series, and laparoscopy was superior in terms of complication rate, surgery in children. J. Urol., 151: 735, 1994. postoperative recovery and hospital stay. The only disadvantage was 5. Figenshau, R. S.,Clayman, R. V., Kerbl, K., McDougall, E. M. the longer operative time, which, however, did not lead to increased and Colberg, J. W.: Laparoscopic nephroureterectomy in the morbidity.’ These data were not included in our publication, since child initial case report. J. Urol., 151: 740, 1994. the open surgical group was not a contemporary but a historical 6. Janetachek, G.,Reissigl, A, Peschel, R. and Bartsch, G.: Lapa- series. We agree that a prospective randomized study would be roscopic nephroureterectomy in infants. J. Endourol., suppl. 7, helpful to settle the issue. However, as soon as one has come to the 4:236,abstract V-144,1993. conclusion that of 2 alternative techniques one is superior to the 7. Kerbl, K, Clayman, R. V., McDougall, E. M., Gill, I. S., Wilson, other, it is impossible to perform such a comparative study, since a B. S., Chandhoke, P. S., Albala, D. M. and Kavoussi, L. R.: group of patients would have to be subjected to an operation considTransperitoneal nephredomy for benign disease of the kidney: ered to be suboptimal. a comparison of laparoscopic and open surgical techniques. 1. Janetschek, G., Seibold, J., Radmayr, C. and Bartsch, G.: Urology, 43:607,1994. Pediatric heminephroureterectomy in children: laparoscopy 8. Cortesi, N., Ferrari, P., Zambarda, E., Manenti, A., Baldini, A. versus open surgery. J. Endourol., suppl. 1, 1 0 5170,abstract and Morano, F. P.: Diagnosis of bilateral abdominal cryp.. P15-440,1996. torchism by laparoscopy.Endoscopy, 8: 33, 1976.