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Pediatric urological laparoendoscopic single site surgery: Single surgeon experience
Journal of Pediatric Urology (2014) 10, 1170e1175
Pediatric urological laparoendoscopic single site surgery: Single surgeon experience Danesh Bansal, Nicholas G. Cost, Christopher M. Bean, Eugene A. Minevich, Paul H. Noh* Division of Pediatric Urology, Cincinnati Children’s Hospital Medical Center, 3333 Burnet Avenue, ML 5037, Cincinnati, OH 45229, USA Received 7 October 2013; accepted 29 April 2014
Available online 19 June 2014
KEYWORDS Pediatric; Laparoendoscopic single site; Laparoscopy; Urological
Abstract Objective: The aim was to assess the feasibility and outcomes of pediatric urological laparoendoscopic single site (LESS) surgery. Materials and methods: A retrospective review was performed of all children who underwent LESS surgery at a single pediatric institution from September 2010 to July 2013. Patient demographics, intraoperative details, narcotic usage, and complications were reviewed. The umbilicus was used as the surgical site in all cases. All procedures were performed with a flexible tip laparoscope, a multichannel port, standard 3- or 5-mm laparoscopic instrumentation, and articulating instruments. Results: Sixty-one patients (50 male, 11 female) were identified. Procedures included 18 orchidopexies, 15 nephrectomies, 11 varicocelectomies, nine nephroureterectomies, four partial nephrectomies, one ureterectomy, one ureterolithotomy, one orchiectomy, and one utricle excision. The ureterolithotomy was converted to open surgery for failure to progress. The utricle excision was converted to conventional laparoscopy by adding one accessory port and one skin puncture because of the close proximity of the vas deferens to the utricle. Intraoperative complications included one vas deferens injury during orchidopexy in a postpubertal male. Postoperative complications occurred in six patients: five grade II and one grade IIIb. Conclusions: Pediatric urological LESS procedures are technically feasible, safe, and effective. Further evaluation is warranted to better define its role in pediatric urological surgery. ª 2014 Journal of Pediatric Urology Company. Published by Elsevier Ltd. All rights reserved.
* Corresponding author. Division of Pediatric Urology, Cincinnati Children’s Hospital Medical Center, 3333 Burnet Avenue, ML 5037, Cincinnati, OH 45229, USA. Tel.: þ1 513 636 4975 (office); fax: þ1 513 636 6753. E-mail address: [email protected] (P.H. Noh). http://dx.doi.org/10.1016/j.jpurol.2014.04.020 1477-5131/ª 2014 Journal of Pediatric Urology Company. Published by Elsevier Ltd. All rights reserved.
Pediatric urological laparoendoscopic single site surgery
Introduction Laparoscopic surgery has gained wide acceptance as the standard of care for many adult and pediatric urological procedures. With increasing experience in minimally invasive surgery (MIS), efforts are being directed at further minimizing morbidity and improving cosmesis, including in the pediatric population. Developed as an extension of standard laparoscopy, laparoendoscopic single site (LESS) seeks to minimize patient discomfort, decrease convalescence, and improve cosmesis by placing all instruments through a single skin incision. This has led to the development of novel techniques, new ports, and specialized instruments that allow laparoscopy to be performed through a single skin incision often hidden within the umbilicus [1e4]. Since the initial report of single port nephrectomy in 2007, LESS has been utilized for diverse urological diseases. Studies on postoperative outcomes demonstrate less pain, a reduced hospital stay, and excellent cosmesis compared with other forms of MIS [5e7]. Single port devices, until recently, were designed mainly for use in adults, and, therefore, their applicability and use in children was limited. Additionally, questions remain regarding the comparative benefit, potentially lengthy learning curve, technical limitations of existing instrumentation, reproducibility, adoption, and dissemination of the technique [5,8]. We report a single surgeon experience with LESS surgery to assess the technical feasibility and outcomes of this technique for different pediatric urological procedures.
1171 a 5-mm flexible tip laparoscope that delivers a 100-degree angulation and an 85-degree field of view. The TriPort and GelPOINT Mini are multichannel single port devices that are placed via an open technique through a skin and fascial incision. Patients were placed supine or in semi-flank position for upper urinary tract procedures. Port placement was through a midline umbilical incision. The length of the incision was intentionally not measured. The top and bottom of the umbilical ring were typically used as landmarks for the cranial and caudal ends of the skin incision, to hide the incision in the umbilicus. The multichannel port was introduced. Two instruments and the laparoscope were utilized. Percutaneous traction sutures were utilized for upper urinary tract procedures on a case-by-case basis to facilitate exposure. Patients received local anesthesia at the umbilical incision. Regional blocks were administered based on shared decision-making by the family, surgeon, and anesthesiologist. Postoperative inpatient analgesia typically included alternating scheduled ketorolac and acetaminophen with narcotics as needed. Narcotic utilization was converted to morphine sulfate equivalents for data analysis. Length of stay and analgesic utilization were analyzed for inpatient surgery and excluded concomitant procedures and conversions to open or laparoscopic surgery. Patients were followed postoperatively for evidence of remote adverse events. Success was defined as completion of the intended LESS procedure without the need for conversion. All surgical complications were classified according to the Clavien classification scheme [13].
Results Materials and methods A retrospective, descriptive, non-randomized, observational review was performed to assess the feasibility and outcomes of LESS urological surgery in the pediatric population. The medical records of all patients who underwent LESS surgery at a single pediatric institution, from the introduction of LESS surgery in September 2010eJuly 2013, were reviewed. Chart review was performed after Institutional Review Board approval. A single surgeon performed all procedures. Data included patient demographics, intraoperative details, narcotic usage, and complications. Urinary tract reconstructive procedures were not performed using LESS because of the surgeon’s practice pattern of performing robot-assisted laparoscopy for those procedures. After discussion of all treatment options, families specifically consented to LESS surgery. Operative times were obtained from anesthesia records and began at the start of the surgical incision and ended when the skin incision was closed. Operative times included cystoscopy, when performed, and patient repositioning. In-depth operative details for LESS nephrectomy, orchidopexy, nephroureterectomy, and varicocelectomy have previously been reported [9e12]. In general, surgical procedures were performed with an Olympus EndoEye, an Olympus TriPort-Tokyo, Japan or Applied Medical GelPOINT Mini-Rancho Santa Margarita, CA, USA, standard 3- or 5-mm laparoscopic instrumentation, and Cambridge Endo articulating instruments in select cases. The Olympus EndoEye is
Sixty-one patients (male, 50; female, 11) underwent transperitoneal LESS urological surgery. Patient demographics are shown in Table 1. Median age and body mass index of the entire cohort was 28.9 months (range 2.5e239.7 months) and 17.5 kg/m2 (range 14.6e33.6 kg/ m2), respectively. Nine different types of procedures were performed. Surgical indications and operative times are shown in Table 2. Six out of 18 (33%) orchidopexies were staged FowlereStephens (FS) (3 right, 3 left) procedures. Two bilateral orchidopexies and one bilateral varicocelectomy were performed. Median operative time for the entire cohort was 72 min (range 33e314 min). There was no significant intraoperative blood loss. Two procedures were converted to facilitate the surgery. The ureterolithotomy with antegrade ureteroscopy for impacted ureteral stones was converted to open surgery for failure to progress. The utricle excision was converted to conventional laparoscopy due to the close proximity of the vas deferens to the dilated utricle. An additional 5-mm port was placed under direct vision on the left side of the abdomen, and a skin puncture was placed on the right side of the abdomen for additional instrumentation. One intraoperative complication occurred, which was a vas deferens injury during an orchidopexy in a postpubertal male. Thirty-seven (61%) patients were discharged on the same day as surgery. Outpatient procedures included orchidopexy (n Z 15), nephrectomy (n Z 9), varicocelectomy
1172 Table 1
D. Bansal et al. Patient demographics.
Procedure
No. (%) patients
Median age, month (range)
Median weight, kg (range)
Median height, m (range)
Median BMI, kg/m2 (range)
Median BMI percentile, % (range)
Orchidopexy Nephrectomy Varicocelectomy Nephroureterectomy Partial nephrectomy Ureterectomy Ureterolithotomy Orchiectomy Utricle excision Total
18 15 11 9 4 1 1 1 1 61
11 (3.8e147.3) 19.4 (7.3e169.6) 184 (149e239.7) 61.3 (16.3e144.9) 6.2 (2.5e16.4) 25.3 135 162 10.9 28.9 (2.5e239.7)
10.1 (4e54.5) 10.5 (7.3e72.3) 62 (35.4e83) 17 (10.7e41.2) 8.1 (6.1e12.6) 12.5 31.2 59 10.8 12.6 (4e83)
0.75 (0.46e1.63) 0.81 (0.67e1.59) 1.74 (1.48e1.85) 0.99 (0.71e1.36) 0.67 (0.6e0.85) 0.8 1.4 1.6 0.8 0.8 (0.46e1.85)
17.3 16.9 20.7 17.4 17.2 18.4 15.4 21.9 16.9 17.5
69.5 (7e99) 63 (5e98) 67 (16e98) 75 (29e99) 66.5 (45e85) 90 14 84 50 67 (5e99)
(30%) (25%) (18%) (15%) (7%) (2%) (2%) (2%) (2%)
(n Z 10), nephroureterectomy (n Z 1), partial nephrectomy (n Z 1), and orchiectomy (n Z 1). Twenty (33%) patients had LESS procedures with an inpatient stay included for perioperative data analysis. These procedures included nephroureterectomy (n Z 6), nephrectomy (n Z 6), orchidopexy (n Z 3), partial nephrectomy (n Z 3), ureterectomy (n Z 1), and varicocelectomy (n Z 1). Four (6%) patients were excluded from the inpatient data analysis because of conversion to open or laparoscopic surgery or concomitant procedures. Excluded procedures were nephroureterectomy (2), ureterolithotomy (1), and utricle excision (1). Median length of stay for inpatient procedures is shown in Table 3. A minority of patients had hospital stays with extenuating factors. One patient with prune belly syndrome was unable to be weaned from the ventilator in the postanesthesia care unit after a primary FS orchidopexy. The same patient underwent a contralateral primary FS orchidopexy 4 months later. The patient was admitted
Table 2
(14.6e28) (14.6e28.7) (16.2e26.3) (14.9e33.6) (16.8e18)
(14.6e33.6)
overnight for postoperative observation because of a history of respiratory failure after surgery in the past. A second patient after orchidopexy was admitted overnight because of a platelet function defect. The patient had a history of increased bleeding after surgery. A 19-year-old patient after bilateral varicocelectomy was admitted postoperatively for 4 days because of increased pain at the site of the abdominal incision and severe pruritus from multiple pain medications, which led to a prolonged hospital stay due to difficulty with optimizing pain management. Two patients undergoing nephroureterectomy had concomitant procedures accounting for extended stays. One patient had a concomitant adenotonsillectomy and was admitted postoperatively for 4 days because of nocturnal hypoxia and atelectasis. Another patient was admitted for 6 days recovering from an open ureteral reimplantation. The patient undergoing ureterectomy had a febrile urinary tract infection, treated with intravenous antibiotics, and a prolonged ileus, due to an infected obstructed system after
Surgical indications and operative times.
Procedure
No. (%) patients
Surgical indication
Operative time (min), median (range)
Orchidopexy Nephrectomy
18 (30%) 15 (25%)
56 (42e101) 90 (46e136)
Varicocelectomy
11 (18%)
Intra-abdominal undescended testis (18) Enlarging multicystic dysplastic kidney (10) UPJO with poorly functioning kidney (5) Scrotal pain (7) Testicular hypotrophy (3) Grade increase (1) Obstructed ectopic megaureter with poorly functioning kidney (5) Vesicoureteral reflux with poorly functioning kidney (4) Obstructed ectopic ureter with poorly functioning upper pole moiety (2) Obstructed ureterocele with poorly functioning upper pole moiety (1) UPJO with poorly functioning lower pole moiety (1) Recurrent infections of retained obstructed ectopic ureter (1) Impacted ureteral stones (1) Postpubertal intra-abdominal testis (1) Dilated fluid-filled structure posterior to the bladder (1)
Nephroureterectomy
9 (15%)
Partial nephrectomy
4 (7%)
Ureterectomy Ureterolithotomy Orchiectomy Utricle excision Total a
1 1 1 1 61
(2%) (2%) (2%) (2%)
Operative time reflects entire procedure including conversions.
49 (33e76)
174 (74e222) 126 (97e180)
246 314a 59 113a 72 (33e314)
Pediatric urological laparoendoscopic single site surgery Table 3
1173
Perioperative data for inpatient procedures.a
LESS procedure
No. patients
Hospital stay (days), median (range)
Morphine equivalent (mg/kg/day), median (range)
Ketorolac (mg/kg/day), median (range)
Acetaminophen (mg/kg/day), median (range)
Orchidopexy Nephrectomy Varicocelectomy Nephroureterectomy Partial nephrectomy Ureterectomy Total
3 6 1 6 3 1 20
1 1 (1e2) 4 1 1 (1e2) 4 1 (1e2)
0.04 (0.02e0.05) 0.07 0.06 0.02 0 0 0.05 (0.02e0.07)
0 0.76 (0.22e1.22) 0 0.43 (0.25e0.75) 0.50 (0.25e0.74) 0.3 0.5 (0.22e1.22)
7.77 (5.12e14.6) 18.53 (6.11e22.19) 20.8 19.89 (7.5e29.91) 11.39 (10.32e23.16) 2.56 14.84 (2.56e23.16)
a
Excludes conversions to open or laparoscopic surgery and patients with concomitant procedures.
previous partial nephrectomy for an upper urinary tract duplication anomaly. Postoperative analgesic data for inpatient procedures are shown in Table 3. Median inpatient postoperative narcotic use, ketorolac, and acetaminophen use among patients undergoing inpatient surgery was 0.05 mg/kg/day (range 0.02e0.07 mg/kg/day), 0.5 mg/kg/day (range 0.22e1.22 mg/kg/day), and 14.84 mg/kg/day (range 2.56e23.16 mg/kg/day), respectively. All patients returned for follow-up visits. All orchidopexies and varicocelectomies were successful. There were no significant abnormalities on postoperative ultrasounds for upper urinary tract procedures. No postoperative umbilical hernias were noted. Postoperative complications occurred in six patients: five grade II and one grade IIIb. Significant surgical complications, defined as grade IIIa or higher, occurred in 1.6% (1/61) of the procedures. The patient undergoing ureterectomy has been previously described. Two patients undergoing nephrectomy presented to the emergency department with port site infections on postoperative days 25 and 34. Both patients were managed with outpatient oral antibiotics. One patient undergoing nephroureterectomy had an umbilical infection, managed with outpatient oral antibiotics. A patient undergoing orchidopexy developed scrotal cellulitis, which was treated with outpatient oral antibiotics. Lastly, one patient undergoing varicocelectomy developed a postoperative hydrocele, which was managed with a secondary open procedure. LESS surgery was successfully completed in 59 out of 61 (97%) patients without the need for ancillary ports or additional instrument insertion sites.
Discussion Pediatric laparoscopic nephrectomy was first described in 1992 [14]. Since that time, laparoscopy has gained wide acceptance for surgical treatment of various pathological entities in pediatric urology. However, potential shortcomings still remain. Each laparoscopic port potentially increases patient morbidity because of visceral or vascular injury, bleeding from abdominal wall vessels, and incisional hernias. Recent technological innovations have subsequently contributed to the development of LESS surgery. LESS access can be achieved with a variety of techniques. A common approach is to make a single skin and
fascial incision, through which a single multichannel access platform (single port) or multiple 3- or 5-mm ports are placed. The latter prevents the need for a multichannel port and may potentially reduce the cost. Some surgeons also use a single skin incision and multiple fascial incisions to obviate a special port. LESS surgery may potentially improve cosmesis compared to conventional laparoscopy or robot-assisted laparoscopy. A longer skin incision is more readily hidden in the umbilicus for LESS surgery. All procedures in this series were started with a midline umbilical skin incision, favored over an infraumbilical curvilinear incision, due to ease of initial access through the natural defect of a persistent small umbilical hernia defect, which is typically present, and the surgeon’s opinion that the midline incision achieves the most favorable postoperative cosmetic result. An even longer fascial incision can be created under the umbilical skin incision if needed for instruments or to retrieve a specimen. For extirpative procedures with conventional laparoscopy, commonly one incision must be lengthened, or another incision made, to remove the surgical specimen [15]. An advantage of LESS surgery is that the entire procedure, including removal of the specimen, can be performed through one incision. The evolution of single port devices, articulating and pre-bent instruments, and flexible laparoscopes has contributed to application of LESS amongst urologists. Since the initial report of LESS nephrectomy by Raman et al. [3] (transumbilical, multiple ports) and Rane et al. [4] (single port device, extraumbilical incision), several investigators have demonstrated the technical feasibility of a variety of urological LESS procedures. However, there have been few reports with limited experience on pediatric LESS, which remains in its infancy. To the best of our knowledge, we report the largest experience with pediatric urological LESS procedures. Our experience supports the continued use of LESS surgery in the pediatric population. A single pediatric urologist, with extensive laparoscopic and robotic surgery experience, performed all procedures. All procedures resulted in a surgical scar that was concealed within the umbilicus. Fifty-nine out of 61 (97%) patients underwent successful LESS operations. Only two conversions were necessary. Both patients underwent successful procedures without intraoperative or postoperative complications, and conversion was not considered a complication in these patients.
1174 In our study, the median operative time of 72 min is considerably less than large adult studies reporting their initial experience with LESS surgery and studies investigating conventional pediatric laparoscopy [7,16,17]. However, this may be due to different indications for adult and pediatric LESS surgery. Our operative time is comparable to previous cases of pediatric LESS nephrectomy and nephroureterectomy [12,18,19]. Our experience indicates that LESS surgery has the potential for minimal postoperative pain. As experience was gained, upper urinary tract procedures, which are typically inpatient procedures, were performed on an outpatient basis. Single port surgery involves several technical challenges. These include triangulation difficulties, difficult working angles, difficulty retracting, limited instrumentation, instrument crowding, and crossing instruments [20]. Maneuverability of instruments is more difficult with one port but may be overcome through the learning curve. Additionally, LESS surgery may be more challenging in the pediatric population due to the limited working space. Pre-bent and flexible instruments may be less beneficial in the smaller working space of infants and small children. On the contrary, one benefit in the pediatric population includes a shorter distance from the umbilicus to target organ site. Until recently, single port devices were mainly designed for use in adults. In our experience, maintaining pneumoperitoneum was compromised in some cases with infants and small children by the multichannel port device, specifically related to a leak from the individual port when an instrument was being used through it. In patients with a very small working space, a multichannel port with gel seals on the ports was used to minimize the potential for air leaks instead of ports with a duckbill sealing mechanism. A larger working space in an adult may have been less affected by a similar problem. Ports with a gel seal were more prone to sticking to the instruments versus ports with a duckbill seal. This was addressed by adequately lubricating the shaft of the laparoscopic instruments. Additional access was utilized in only one patient to complete a laparoscopic procedure. Koh et al. [12] required an accessory port in five of 11 pediatric LESS nephrectomies. Other surgeons may opt to insert 3-mm instruments percutaneously without an additional port as an alternative to larger trocars for additional access. To avoid external instrument collisions, instruments of different lengths may be utilized. The use of a flexible laparoscope was critical to mitigate instrument collisions and minimize a compromised field of view, especially avoiding an inline view down the shaft of a rigid instruments, which were most commonly used for our procedures. Reconstructive procedures, such as pyeloplasty for ureteropelvic junction obstruction, were not performed in our series. The main contributing factor for this is the surgeon’s practice of utilizing robot-assisted laparoscopy for reconstructive procedures. This may not be universally applicable, or preferable, due to the expense of acquiring and maintaining a robotic surgical system. Pediatric LESS pyeloplasty has been recently reported with favorable early outcomes [21e23]. Pediatric LESS ureteral reimplantation and ureteroureterostomy have not yet been reported. The advanced skill set required to perform LESS reconstructive procedures may not be transferable to all surgeons.
D. Bansal et al. Although a LESS platform is available for adult robotassisted laparoscopy and has been performed, it may not be suitable for the pediatric population. Further evolution of robotic technology will be needed before it is applicable for use in infants and children, as a means to allow more surgeons to consider LESS reconstruction in the pediatric population. Our study has several limitations. Some may consider a single surgeon experience a limitation, while some may consider it an advantage. The LESS technique was not assessed against other forms of MIS because of the heterogeneity of the procedures performed. No objective assessment of cosmesis, patient/family satisfaction, or cost analysis was performed, again in part due to the varying procedures performed.
Conclusions Our initial experience demonstrates that LESS is feasible, safe, and effective for various pediatric urological procedures. Further applications of this procedure in a larger group of patients and prospective assessment to compare it to other surgical approaches are warranted to better define the role for LESS surgery in pediatric urology.
Conflict of interest None.
Funding None.
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laparoscopic nephroureterectomy and laparoendoscopic single-site nephroureterectomy. Urology 2014;83:438e42. Bansal D, Riachy E, Defoor Jr WR, Reddy PP, Minevich EA, Alam S, et al. Pediatric varicocelectomy: a comparative study of conventional laparoscopic and laparoendoscopic single-site approaches. J Endourol 2014;28:513e6. Noh PH, Vinson MA, Bansal D. Laparoendoscopic single site orchidopexy for intra-abdominal testes in the pediatric population with a multichannel single port and flexible tip laparoscope. J Endourol 2013;27:1381e3. Koh CJ, De Filippo RE, Chang AY, Hardy BE, Berger A, Eisenberg M, et al. Laparoendoscopic single-site nephrectomy in pediatric patients: initial clinical series of infants to adolescents. Urology 2010;76:1457e61. Dindo D, Demartines N, Clavien P-A. Classification of surgical complications. Ann Surg 2004;240:205e13. Koyle MA, Woo HH, Kavoussi LR. Laparoscopic nephrectomy in the first year of life. J Pediatr Urol 1993;28:693e5. Kocherov S, Lev G, Shenfeld OZ, Chertin B. Laparoscopic single site surgery: initial experience and description of techniques in the pediatric population. J Urol 2011;186:1653e7. Desai MM, Berger AK, Brandina R, Aron M, Irwin BH, Canes D, et al. Laparoendoscopic single-site surgery: initial hundred patients. Urology 2009;74:805e12.
1175 [17] Fuchs J, Luithle T, Warmann SW, Haber P, Blumenstock G, Szavay P. Laparoscopic surgery on upper urinary tract in children younger than 1 year: technical aspects and functional outcome. J Urol 2009;182:1561e8. [18] Luithle T, Szavay P, Fuchs J. Single-incision laparoscopic nephroureterectomy in children of all age groups. J Pediatr Surg 2013;48:1142e6. [19] Ham WS, Im YJ, Jung HJ, Hong CH, Han WK, Han SW. Initial experience with laparoendoscopic single-site nephrectomy and nephroureterectomy in children. Urology 2011;77:1204e8. [20] Weibl P, Klingler HC, Klatte T, Remzi M. Current limitations and perspectives in single port surgery: pros and cons laparoendoscopic single-site surgery (LESS) for renal surgery. Diagn Ther Endosc 2010;2010:759431. [21] Bi Y, Lu L, Ruan S. Using conventional 3- and 5-mm straight instruments in laparoendoscopic single-site pyeloplasty in children. J Laparoendosc Adv Surg Tech A 2011;21:969e72. [22] Tugcu V, Ilbey YO, Polat H, Tasci AI. Early experience with laparoendoscopic single-site pyeloplasty in children. J Pediatr Urol 2011;7:187e91. [23] Zhou H, Sun N, Zhang X, Xie H, Ma L, Shen Z, et al. Transumbilical laparoendoscopic single-site pyeloplasty in infants and children: initial experience and short-term outcome. Pediatr Surg Int 2012;28:321e5.
Pediatric urological laparoendoscopic single site surgery: Single surgeon experience Danesh Bansal, Nicholas G. Cost, Christopher M. Bean, Eugene A. Minevich, Paul H. Noh* Division of Pediatric Urology, Cincinnati Children’s Hospital Medical Center, 3333 Burnet Avenue, ML 5037, Cincinnati, OH 45229, USA Received 7 October 2013; accepted 29 April 2014
Available online 19 June 2014
KEYWORDS Pediatric; Laparoendoscopic single site; Laparoscopy; Urological
Abstract Objective: The aim was to assess the feasibility and outcomes of pediatric urological laparoendoscopic single site (LESS) surgery. Materials and methods: A retrospective review was performed of all children who underwent LESS surgery at a single pediatric institution from September 2010 to July 2013. Patient demographics, intraoperative details, narcotic usage, and complications were reviewed. The umbilicus was used as the surgical site in all cases. All procedures were performed with a flexible tip laparoscope, a multichannel port, standard 3- or 5-mm laparoscopic instrumentation, and articulating instruments. Results: Sixty-one patients (50 male, 11 female) were identified. Procedures included 18 orchidopexies, 15 nephrectomies, 11 varicocelectomies, nine nephroureterectomies, four partial nephrectomies, one ureterectomy, one ureterolithotomy, one orchiectomy, and one utricle excision. The ureterolithotomy was converted to open surgery for failure to progress. The utricle excision was converted to conventional laparoscopy by adding one accessory port and one skin puncture because of the close proximity of the vas deferens to the utricle. Intraoperative complications included one vas deferens injury during orchidopexy in a postpubertal male. Postoperative complications occurred in six patients: five grade II and one grade IIIb. Conclusions: Pediatric urological LESS procedures are technically feasible, safe, and effective. Further evaluation is warranted to better define its role in pediatric urological surgery. ª 2014 Journal of Pediatric Urology Company. Published by Elsevier Ltd. All rights reserved.
* Corresponding author. Division of Pediatric Urology, Cincinnati Children’s Hospital Medical Center, 3333 Burnet Avenue, ML 5037, Cincinnati, OH 45229, USA. Tel.: þ1 513 636 4975 (office); fax: þ1 513 636 6753. E-mail address: [email protected] (P.H. Noh). http://dx.doi.org/10.1016/j.jpurol.2014.04.020 1477-5131/ª 2014 Journal of Pediatric Urology Company. Published by Elsevier Ltd. All rights reserved.
Pediatric urological laparoendoscopic single site surgery
Introduction Laparoscopic surgery has gained wide acceptance as the standard of care for many adult and pediatric urological procedures. With increasing experience in minimally invasive surgery (MIS), efforts are being directed at further minimizing morbidity and improving cosmesis, including in the pediatric population. Developed as an extension of standard laparoscopy, laparoendoscopic single site (LESS) seeks to minimize patient discomfort, decrease convalescence, and improve cosmesis by placing all instruments through a single skin incision. This has led to the development of novel techniques, new ports, and specialized instruments that allow laparoscopy to be performed through a single skin incision often hidden within the umbilicus [1e4]. Since the initial report of single port nephrectomy in 2007, LESS has been utilized for diverse urological diseases. Studies on postoperative outcomes demonstrate less pain, a reduced hospital stay, and excellent cosmesis compared with other forms of MIS [5e7]. Single port devices, until recently, were designed mainly for use in adults, and, therefore, their applicability and use in children was limited. Additionally, questions remain regarding the comparative benefit, potentially lengthy learning curve, technical limitations of existing instrumentation, reproducibility, adoption, and dissemination of the technique [5,8]. We report a single surgeon experience with LESS surgery to assess the technical feasibility and outcomes of this technique for different pediatric urological procedures.
1171 a 5-mm flexible tip laparoscope that delivers a 100-degree angulation and an 85-degree field of view. The TriPort and GelPOINT Mini are multichannel single port devices that are placed via an open technique through a skin and fascial incision. Patients were placed supine or in semi-flank position for upper urinary tract procedures. Port placement was through a midline umbilical incision. The length of the incision was intentionally not measured. The top and bottom of the umbilical ring were typically used as landmarks for the cranial and caudal ends of the skin incision, to hide the incision in the umbilicus. The multichannel port was introduced. Two instruments and the laparoscope were utilized. Percutaneous traction sutures were utilized for upper urinary tract procedures on a case-by-case basis to facilitate exposure. Patients received local anesthesia at the umbilical incision. Regional blocks were administered based on shared decision-making by the family, surgeon, and anesthesiologist. Postoperative inpatient analgesia typically included alternating scheduled ketorolac and acetaminophen with narcotics as needed. Narcotic utilization was converted to morphine sulfate equivalents for data analysis. Length of stay and analgesic utilization were analyzed for inpatient surgery and excluded concomitant procedures and conversions to open or laparoscopic surgery. Patients were followed postoperatively for evidence of remote adverse events. Success was defined as completion of the intended LESS procedure without the need for conversion. All surgical complications were classified according to the Clavien classification scheme [13].
Results Materials and methods A retrospective, descriptive, non-randomized, observational review was performed to assess the feasibility and outcomes of LESS urological surgery in the pediatric population. The medical records of all patients who underwent LESS surgery at a single pediatric institution, from the introduction of LESS surgery in September 2010eJuly 2013, were reviewed. Chart review was performed after Institutional Review Board approval. A single surgeon performed all procedures. Data included patient demographics, intraoperative details, narcotic usage, and complications. Urinary tract reconstructive procedures were not performed using LESS because of the surgeon’s practice pattern of performing robot-assisted laparoscopy for those procedures. After discussion of all treatment options, families specifically consented to LESS surgery. Operative times were obtained from anesthesia records and began at the start of the surgical incision and ended when the skin incision was closed. Operative times included cystoscopy, when performed, and patient repositioning. In-depth operative details for LESS nephrectomy, orchidopexy, nephroureterectomy, and varicocelectomy have previously been reported [9e12]. In general, surgical procedures were performed with an Olympus EndoEye, an Olympus TriPort-Tokyo, Japan or Applied Medical GelPOINT Mini-Rancho Santa Margarita, CA, USA, standard 3- or 5-mm laparoscopic instrumentation, and Cambridge Endo articulating instruments in select cases. The Olympus EndoEye is
Sixty-one patients (male, 50; female, 11) underwent transperitoneal LESS urological surgery. Patient demographics are shown in Table 1. Median age and body mass index of the entire cohort was 28.9 months (range 2.5e239.7 months) and 17.5 kg/m2 (range 14.6e33.6 kg/ m2), respectively. Nine different types of procedures were performed. Surgical indications and operative times are shown in Table 2. Six out of 18 (33%) orchidopexies were staged FowlereStephens (FS) (3 right, 3 left) procedures. Two bilateral orchidopexies and one bilateral varicocelectomy were performed. Median operative time for the entire cohort was 72 min (range 33e314 min). There was no significant intraoperative blood loss. Two procedures were converted to facilitate the surgery. The ureterolithotomy with antegrade ureteroscopy for impacted ureteral stones was converted to open surgery for failure to progress. The utricle excision was converted to conventional laparoscopy due to the close proximity of the vas deferens to the dilated utricle. An additional 5-mm port was placed under direct vision on the left side of the abdomen, and a skin puncture was placed on the right side of the abdomen for additional instrumentation. One intraoperative complication occurred, which was a vas deferens injury during an orchidopexy in a postpubertal male. Thirty-seven (61%) patients were discharged on the same day as surgery. Outpatient procedures included orchidopexy (n Z 15), nephrectomy (n Z 9), varicocelectomy
1172 Table 1
D. Bansal et al. Patient demographics.
Procedure
No. (%) patients
Median age, month (range)
Median weight, kg (range)
Median height, m (range)
Median BMI, kg/m2 (range)
Median BMI percentile, % (range)
Orchidopexy Nephrectomy Varicocelectomy Nephroureterectomy Partial nephrectomy Ureterectomy Ureterolithotomy Orchiectomy Utricle excision Total
18 15 11 9 4 1 1 1 1 61
11 (3.8e147.3) 19.4 (7.3e169.6) 184 (149e239.7) 61.3 (16.3e144.9) 6.2 (2.5e16.4) 25.3 135 162 10.9 28.9 (2.5e239.7)
10.1 (4e54.5) 10.5 (7.3e72.3) 62 (35.4e83) 17 (10.7e41.2) 8.1 (6.1e12.6) 12.5 31.2 59 10.8 12.6 (4e83)
0.75 (0.46e1.63) 0.81 (0.67e1.59) 1.74 (1.48e1.85) 0.99 (0.71e1.36) 0.67 (0.6e0.85) 0.8 1.4 1.6 0.8 0.8 (0.46e1.85)
17.3 16.9 20.7 17.4 17.2 18.4 15.4 21.9 16.9 17.5
69.5 (7e99) 63 (5e98) 67 (16e98) 75 (29e99) 66.5 (45e85) 90 14 84 50 67 (5e99)
(30%) (25%) (18%) (15%) (7%) (2%) (2%) (2%) (2%)
(n Z 10), nephroureterectomy (n Z 1), partial nephrectomy (n Z 1), and orchiectomy (n Z 1). Twenty (33%) patients had LESS procedures with an inpatient stay included for perioperative data analysis. These procedures included nephroureterectomy (n Z 6), nephrectomy (n Z 6), orchidopexy (n Z 3), partial nephrectomy (n Z 3), ureterectomy (n Z 1), and varicocelectomy (n Z 1). Four (6%) patients were excluded from the inpatient data analysis because of conversion to open or laparoscopic surgery or concomitant procedures. Excluded procedures were nephroureterectomy (2), ureterolithotomy (1), and utricle excision (1). Median length of stay for inpatient procedures is shown in Table 3. A minority of patients had hospital stays with extenuating factors. One patient with prune belly syndrome was unable to be weaned from the ventilator in the postanesthesia care unit after a primary FS orchidopexy. The same patient underwent a contralateral primary FS orchidopexy 4 months later. The patient was admitted
Table 2
(14.6e28) (14.6e28.7) (16.2e26.3) (14.9e33.6) (16.8e18)
(14.6e33.6)
overnight for postoperative observation because of a history of respiratory failure after surgery in the past. A second patient after orchidopexy was admitted overnight because of a platelet function defect. The patient had a history of increased bleeding after surgery. A 19-year-old patient after bilateral varicocelectomy was admitted postoperatively for 4 days because of increased pain at the site of the abdominal incision and severe pruritus from multiple pain medications, which led to a prolonged hospital stay due to difficulty with optimizing pain management. Two patients undergoing nephroureterectomy had concomitant procedures accounting for extended stays. One patient had a concomitant adenotonsillectomy and was admitted postoperatively for 4 days because of nocturnal hypoxia and atelectasis. Another patient was admitted for 6 days recovering from an open ureteral reimplantation. The patient undergoing ureterectomy had a febrile urinary tract infection, treated with intravenous antibiotics, and a prolonged ileus, due to an infected obstructed system after
Surgical indications and operative times.
Procedure
No. (%) patients
Surgical indication
Operative time (min), median (range)
Orchidopexy Nephrectomy
18 (30%) 15 (25%)
56 (42e101) 90 (46e136)
Varicocelectomy
11 (18%)
Intra-abdominal undescended testis (18) Enlarging multicystic dysplastic kidney (10) UPJO with poorly functioning kidney (5) Scrotal pain (7) Testicular hypotrophy (3) Grade increase (1) Obstructed ectopic megaureter with poorly functioning kidney (5) Vesicoureteral reflux with poorly functioning kidney (4) Obstructed ectopic ureter with poorly functioning upper pole moiety (2) Obstructed ureterocele with poorly functioning upper pole moiety (1) UPJO with poorly functioning lower pole moiety (1) Recurrent infections of retained obstructed ectopic ureter (1) Impacted ureteral stones (1) Postpubertal intra-abdominal testis (1) Dilated fluid-filled structure posterior to the bladder (1)
Nephroureterectomy
9 (15%)
Partial nephrectomy
4 (7%)
Ureterectomy Ureterolithotomy Orchiectomy Utricle excision Total a
1 1 1 1 61
(2%) (2%) (2%) (2%)
Operative time reflects entire procedure including conversions.
49 (33e76)
174 (74e222) 126 (97e180)
246 314a 59 113a 72 (33e314)
Pediatric urological laparoendoscopic single site surgery Table 3
1173
Perioperative data for inpatient procedures.a
LESS procedure
No. patients
Hospital stay (days), median (range)
Morphine equivalent (mg/kg/day), median (range)
Ketorolac (mg/kg/day), median (range)
Acetaminophen (mg/kg/day), median (range)
Orchidopexy Nephrectomy Varicocelectomy Nephroureterectomy Partial nephrectomy Ureterectomy Total
3 6 1 6 3 1 20
1 1 (1e2) 4 1 1 (1e2) 4 1 (1e2)
0.04 (0.02e0.05) 0.07 0.06 0.02 0 0 0.05 (0.02e0.07)
0 0.76 (0.22e1.22) 0 0.43 (0.25e0.75) 0.50 (0.25e0.74) 0.3 0.5 (0.22e1.22)
7.77 (5.12e14.6) 18.53 (6.11e22.19) 20.8 19.89 (7.5e29.91) 11.39 (10.32e23.16) 2.56 14.84 (2.56e23.16)
a
Excludes conversions to open or laparoscopic surgery and patients with concomitant procedures.
previous partial nephrectomy for an upper urinary tract duplication anomaly. Postoperative analgesic data for inpatient procedures are shown in Table 3. Median inpatient postoperative narcotic use, ketorolac, and acetaminophen use among patients undergoing inpatient surgery was 0.05 mg/kg/day (range 0.02e0.07 mg/kg/day), 0.5 mg/kg/day (range 0.22e1.22 mg/kg/day), and 14.84 mg/kg/day (range 2.56e23.16 mg/kg/day), respectively. All patients returned for follow-up visits. All orchidopexies and varicocelectomies were successful. There were no significant abnormalities on postoperative ultrasounds for upper urinary tract procedures. No postoperative umbilical hernias were noted. Postoperative complications occurred in six patients: five grade II and one grade IIIb. Significant surgical complications, defined as grade IIIa or higher, occurred in 1.6% (1/61) of the procedures. The patient undergoing ureterectomy has been previously described. Two patients undergoing nephrectomy presented to the emergency department with port site infections on postoperative days 25 and 34. Both patients were managed with outpatient oral antibiotics. One patient undergoing nephroureterectomy had an umbilical infection, managed with outpatient oral antibiotics. A patient undergoing orchidopexy developed scrotal cellulitis, which was treated with outpatient oral antibiotics. Lastly, one patient undergoing varicocelectomy developed a postoperative hydrocele, which was managed with a secondary open procedure. LESS surgery was successfully completed in 59 out of 61 (97%) patients without the need for ancillary ports or additional instrument insertion sites.
Discussion Pediatric laparoscopic nephrectomy was first described in 1992 [14]. Since that time, laparoscopy has gained wide acceptance for surgical treatment of various pathological entities in pediatric urology. However, potential shortcomings still remain. Each laparoscopic port potentially increases patient morbidity because of visceral or vascular injury, bleeding from abdominal wall vessels, and incisional hernias. Recent technological innovations have subsequently contributed to the development of LESS surgery. LESS access can be achieved with a variety of techniques. A common approach is to make a single skin and
fascial incision, through which a single multichannel access platform (single port) or multiple 3- or 5-mm ports are placed. The latter prevents the need for a multichannel port and may potentially reduce the cost. Some surgeons also use a single skin incision and multiple fascial incisions to obviate a special port. LESS surgery may potentially improve cosmesis compared to conventional laparoscopy or robot-assisted laparoscopy. A longer skin incision is more readily hidden in the umbilicus for LESS surgery. All procedures in this series were started with a midline umbilical skin incision, favored over an infraumbilical curvilinear incision, due to ease of initial access through the natural defect of a persistent small umbilical hernia defect, which is typically present, and the surgeon’s opinion that the midline incision achieves the most favorable postoperative cosmetic result. An even longer fascial incision can be created under the umbilical skin incision if needed for instruments or to retrieve a specimen. For extirpative procedures with conventional laparoscopy, commonly one incision must be lengthened, or another incision made, to remove the surgical specimen [15]. An advantage of LESS surgery is that the entire procedure, including removal of the specimen, can be performed through one incision. The evolution of single port devices, articulating and pre-bent instruments, and flexible laparoscopes has contributed to application of LESS amongst urologists. Since the initial report of LESS nephrectomy by Raman et al. [3] (transumbilical, multiple ports) and Rane et al. [4] (single port device, extraumbilical incision), several investigators have demonstrated the technical feasibility of a variety of urological LESS procedures. However, there have been few reports with limited experience on pediatric LESS, which remains in its infancy. To the best of our knowledge, we report the largest experience with pediatric urological LESS procedures. Our experience supports the continued use of LESS surgery in the pediatric population. A single pediatric urologist, with extensive laparoscopic and robotic surgery experience, performed all procedures. All procedures resulted in a surgical scar that was concealed within the umbilicus. Fifty-nine out of 61 (97%) patients underwent successful LESS operations. Only two conversions were necessary. Both patients underwent successful procedures without intraoperative or postoperative complications, and conversion was not considered a complication in these patients.
1174 In our study, the median operative time of 72 min is considerably less than large adult studies reporting their initial experience with LESS surgery and studies investigating conventional pediatric laparoscopy [7,16,17]. However, this may be due to different indications for adult and pediatric LESS surgery. Our operative time is comparable to previous cases of pediatric LESS nephrectomy and nephroureterectomy [12,18,19]. Our experience indicates that LESS surgery has the potential for minimal postoperative pain. As experience was gained, upper urinary tract procedures, which are typically inpatient procedures, were performed on an outpatient basis. Single port surgery involves several technical challenges. These include triangulation difficulties, difficult working angles, difficulty retracting, limited instrumentation, instrument crowding, and crossing instruments [20]. Maneuverability of instruments is more difficult with one port but may be overcome through the learning curve. Additionally, LESS surgery may be more challenging in the pediatric population due to the limited working space. Pre-bent and flexible instruments may be less beneficial in the smaller working space of infants and small children. On the contrary, one benefit in the pediatric population includes a shorter distance from the umbilicus to target organ site. Until recently, single port devices were mainly designed for use in adults. In our experience, maintaining pneumoperitoneum was compromised in some cases with infants and small children by the multichannel port device, specifically related to a leak from the individual port when an instrument was being used through it. In patients with a very small working space, a multichannel port with gel seals on the ports was used to minimize the potential for air leaks instead of ports with a duckbill sealing mechanism. A larger working space in an adult may have been less affected by a similar problem. Ports with a gel seal were more prone to sticking to the instruments versus ports with a duckbill seal. This was addressed by adequately lubricating the shaft of the laparoscopic instruments. Additional access was utilized in only one patient to complete a laparoscopic procedure. Koh et al. [12] required an accessory port in five of 11 pediatric LESS nephrectomies. Other surgeons may opt to insert 3-mm instruments percutaneously without an additional port as an alternative to larger trocars for additional access. To avoid external instrument collisions, instruments of different lengths may be utilized. The use of a flexible laparoscope was critical to mitigate instrument collisions and minimize a compromised field of view, especially avoiding an inline view down the shaft of a rigid instruments, which were most commonly used for our procedures. Reconstructive procedures, such as pyeloplasty for ureteropelvic junction obstruction, were not performed in our series. The main contributing factor for this is the surgeon’s practice of utilizing robot-assisted laparoscopy for reconstructive procedures. This may not be universally applicable, or preferable, due to the expense of acquiring and maintaining a robotic surgical system. Pediatric LESS pyeloplasty has been recently reported with favorable early outcomes [21e23]. Pediatric LESS ureteral reimplantation and ureteroureterostomy have not yet been reported. The advanced skill set required to perform LESS reconstructive procedures may not be transferable to all surgeons.
D. Bansal et al. Although a LESS platform is available for adult robotassisted laparoscopy and has been performed, it may not be suitable for the pediatric population. Further evolution of robotic technology will be needed before it is applicable for use in infants and children, as a means to allow more surgeons to consider LESS reconstruction in the pediatric population. Our study has several limitations. Some may consider a single surgeon experience a limitation, while some may consider it an advantage. The LESS technique was not assessed against other forms of MIS because of the heterogeneity of the procedures performed. No objective assessment of cosmesis, patient/family satisfaction, or cost analysis was performed, again in part due to the varying procedures performed.
Conclusions Our initial experience demonstrates that LESS is feasible, safe, and effective for various pediatric urological procedures. Further applications of this procedure in a larger group of patients and prospective assessment to compare it to other surgical approaches are warranted to better define the role for LESS surgery in pediatric urology.
Conflict of interest None.
Funding None.
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