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MODEL
Journal of Pediatric Urology (2014) xx, 1e5
Pediatric laparo-endoscopic single site partial nephrectomy: Feasibility in infants and small children for upper urinary tract duplication anomalies D. Bansal, N.G. Cost, C.M. Bean, P.H. Noh* Division of Pediatric Urology, Cincinnati Children’s Hospital Medical Center, 3333 Burnet Avenue, ML 5037, Cincinnati, OH, USA Received 30 September 2013; accepted 24 January 2014
KEYWORDS Partial nephrectomy; Pediatrics; Laparoendoscopic single site; Minimally invasive surgery; Hydroureteronephrosis; Upper urinary tract duplication
Abstract Objective: To assess the feasibility and outcomes of laparo-endoscopic single site (LESS) partial nephrectomy (PN) in infants and small children for upper urinary tract duplication anomalies. Materials and methods: The medical records of all patients undergoing LESS PN at a single pediatric institution were retrospectively reviewed for patient demographics, perioperative details, and outcomes. A cystoscopy was initially performed to place an externalized catheter into the ureter of the ipsilateral normal renal moiety. An Olympus TriPort, an Olympus Endoeye flexible tip laparoscope, standard 3- or 5-mm instrumentation, and a LigaSure Blunt were utilized. Results: Four children (two boys, two girls) underwent LESS PN. Three patients underwent upper pole PN and one underwent lower pole PN. All procedures were performed for poorly functioning obstructed renal moieties (one ureterocele, one ureteropelvic junction obstruction and vesicoureteral reflux, and two ectopic ureters). Median age was 6.2 months (range 2.5e16.4 months). Median weight was 7.7 kg (range 6.1e12.6 kg). Median operative time was 126 min (range 97e180 min). No patient received inpatient postoperative narcotics. Median followup was 9.9 months (range 6.2e19.1 months). No postoperative complications were noted. Postoperative renal ultrasound demonstrated successful resection in all patients. Conclusions: LESS PN is technically feasible, safe, and effective for upper urinary tract duplication anomalies in infants and small children. ª 2014 Journal of Pediatric Urology Company. Published by Elsevier Ltd. All rights reserved.
Abbreviations: MIS, Minimally invasive surgery; LESS, Laparoendoscopic single site; PN, Partial nephrectomy; HN, Heminephroureterectomy. * Corresponding author. Tel.: þ1 513 636 4975; fax: þ1 513 636 6753. E-mail addresses: [email protected], [email protected] (P.H. Noh). http://dx.doi.org/10.1016/j.jpurol.2014.01.025 1477-5131/ª 2014 Journal of Pediatric Urology Company. Published by Elsevier Ltd. All rights reserved.
Please cite this article in press as: Bansal D, et al., Pediatric laparo-endoscopic single site partial nephrectomy: Feasibility in infants and small children for upper urinary tract duplication anomalies, Journal of Pediatric Urology (2014), http://dx.doi.org/10.1016/ j.jpurol.2014.01.025
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2
Introduction The first reported use of laparoscopy for extirpative renal surgery was by Clayman et al. in 1991 [1]. Since then, laparoscopic techniques have been widely adopted within urology. Laparoscopic surgery is now commonly performed for many pediatric urologic conditions. Pediatric patients undergoing laparoscopic extirpative renal surgery have experienced shorter hospital stays, decreased pain medication requirements, and the potential for improved cosmesis [2,3]. Urologists have made significant advances in minimally invasive surgery (MIS). Efforts have continued to further minimize surgical morbidity and improve the postoperative cosmetic outcome to a virtually scar-free appearance. This evolution has led to the introduction of laparo-endoscopic single site (LESS) surgery. This innovative technique accesses the abdominal cavity using a single umbilical incision, through which different laparoscopic instruments are introduced in order to perform a multitude of extirpative and reconstructive surgical procedures. Ablative and reconstructive procedures that can be performed via conventional or robot-assisted laparoscopy have been successfully accomplished using LESS techniques [4e7]. The first two cases of single port surgery in urology were simple nephrectomy and ureterolithotomy performed by Rane et al. in 2007 [8]. Kaouk and Palmer [9] reported the first LESS surgery in three children for varicoceles in 2007. However, there are limited reports of LESS surgery performed in children. To our knowledge, we present the first experience of LESS partial nephrectomy (PN), including infants less than 1 year of age, for upper urinary tract duplication anomalies. This retrospective, descriptive, nonrandomized study was performed to assess the feasibility and outcomes of LESS PN in infants and small children for upper urinary tract duplication anomalies.
Materials and methods The medical records of all children who underwent LESS PN at a single pediatric institution from January 2012 to February 2013 were retrospectively reviewed. Chart review was performed after institutional review board approval. LESS surgery was introduced at our hospital in September 2010. Pediatric LESS PN was offered from January 2012. No patients undergoing LESS PN were excluded. All patients underwent a preoperative renal ultrasound. Preoperative voiding cystourethrograms and diuretic renal scans were performed. Indication for operative intervention included poor function of an obstructed renal moiety in upper urinary tract duplication anomalies. A cystoscopy was initially performed to place an externalized catheter into the ureter of the ipsilateral normal renal moiety, which was removed at the end of the laparoscopic procedure. The ureteral catheter was placed to help identify the normal ureter and prevent injury during the procedure. All procedures were performed via a transperitoneal approach through a single umbilical surgical site for obstructed upper or lower pole renal moieties. Data included age, weight, operative time, blood loss, drain utilization, length of hospital stay, postoperative analgesics, complications, and length of the follow-up period. Operative time was recorded as the
D. Bansal et al. initiation of skin incision until the end of skin closure. Operative time did not include cystoscopy, which was approximately 5 min for ureteral catheter placement. Patient repositioning for the laparoscopic procedure was typically another 10e15 min.
Surgical technique LESS PN was performed with an Olympus Endoeye (Tokyo, Japan) flexible tip laparoscope, Olympus TriPort, standard 3- or 5-mm instrumentation, and a 5-mm LigaSure Blunt (Covidien, Dublin, Ireland). The Olympus Endoeye is a 5-mm flexible tip laparoscope that delivers a 100-degree angulation and an 85-degree field of view. The first-generation Olympus TriPort is a multi-channel single port device that is placed via an open technique. Patients were placed in flank position. Access was obtained via a midline, full-length, unmeasured, umbilical incision, which was based on the appearance of the skin of the umbilical ring, estimated at 1.5e2.0 cm. The fascia was opened under direct vision. The Olympus TriPort and Endoeye were introduced. Standard 3- or 5-mm instruments were utilized. Sharp and blunt dissection was employed to open the posterior peritoneum and expose the retroperitoneal space. A percutaneous Prolene holding suture was placed through the diseased renal parenchyma. The upper pole was approached and exposed primarily for diseased upper pole moieties. The LigaSure Blunt was used to control the renal vessels of the involved moiety and perform the majority of the dissection. The upper pole ureter was mobilized cranial to the renal hilum for diseased upper pole moieties. The lower pole was approached primarily for the case with ureteropelvic junction obstruction. The involved renal pelvis and ureter were mobilized and used as a handle for traction and exposure. The diseased renal parenchyma was amputated using the LigaSure Blunt. The avascular plane was identified and followed, between the upper and lower renal poles. Subsequently, redundant ureter was mobilized and amputated without violating the distal common sheath of the duplicated ureters. The distal ureteral stumps of the ectopic ureters, ureterocele, and the ureteropelvic junction obstruction and vesicoureteral reflux were left open, sealed with the LigaSure Blunt, and ligated with 0-polydioxanone Endoloops, respectively. The specimen was removed intact through the single port trocar site without extension of the skin incision. The umbilical fascia was closed with interrupted 3-0 Vicryl. Local anesthesia was utilized for the umbilical incision. Regional blocks were administered on an individual basis, through shared decision-making between the surgeon, anesthesiologist, and family. Postoperative inpatient analgesia included Ketorolac and Acetaminophen administered in a non-uniform manner. Success was defined as absence of diseased renal moiety on postoperative renal ultrasounds.
Results During the study period, four patients (two boys, two girls) underwent LESS PN. Three patients underwent right upper pole PN and one underwent right lower pole PN. Three of the four (75%) patients were infants. A single surgeon
Please cite this article in press as: Bansal D, et al., Pediatric laparo-endoscopic single site partial nephrectomy: Feasibility in infants and small children for upper urinary tract duplication anomalies, Journal of Pediatric Urology (2014), http://dx.doi.org/10.1016/ j.jpurol.2014.01.025
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Pediatric laparo-endoscopic single site partial nephrectomy
3 traditional laparoscopy, including a reduction in the number of trocar ports with the potential for improved cosmesis, decreased morbidity, and lower analgesic requirements [5,13]. Although experience with LESS surgery in adult urology has been increasing, evidenced by the growing number of reports in the literature, there is a paucity of reports on LESS surgery in pediatric urology. In 2007, Kaouk and Palmer [9] reported the first use of the LESS technique in three patients undergoing varicocelectomy. Park et al. [15] reported the first pediatric LESS nephrectomy for a single system ectopic ureter. Desai et al. [5] first reported LESS pyeloplasty to treat primary ureteropelvic junction obstruction in a 10-year-old. Bayazit et al. [16] first reported LESS nephroureterectomy in a 10-year-old girl due to end-stage reflux nephropathy. Pediatric LESS PN has been reported in a case report for a girl with a benign renal mass [17], and a case series of children undergoing nephrectomy and heminephrectomy [18]. More commonly found are published reports of LESS PN in adults [19,20]. To our knowledge, we present the first experience of LESS PN including infants for upper urinary tract duplication anomalies. We performed LESS PN in children ranging in age from 2.5 to 16.4 months. In this population, LESS PN was feasible, safe, and effective, with similar perioperative parameters to that reported by Jeon et al. [17]. There were no conversions in our series, and operative time was shorter in our cohort than that reported by Tam et al. [18]. A vital assessment with any new innovation is monitoring of patient safety. In the present series, all procedures were technically successful without complications, conversions to open or conventional laparoscopic surgery, need for accessory instrument sites, or use of blood transfusions. The transperitoneal approach provided a virtually scarless result because the surgical incision was hidden in the umbilicus. Compared with previous adult reports of LESS PN, lower complication and conversion rates were noted in our study [21e24]. Although surgical outcomes were encouraging in our study, there still remain challenges with performing LESS
performed all LESS procedures. Clinical data for all patients are shown in Table 1. Three of four (75%) cases were found with antenatal ultrasound. The patient with an obstructed right upper pole moiety and ureterocele presented with a febrile urinary tract infection. Preoperative imaging results are shown in Table 2. Median age at surgery was 6.2 months (range 2.5e16.4 months). Median weight was 7.7 kg (range 6.1e12.6 kg). Median height was 66.5 cm (range 60.0e85.1 cm). Median operative time was 126 min (range 97e180 min). There was no significant blood loss, intraoperative complications, or conversions to open or conventional laparoscopy during any procedure. No blood transfusions or accessory incisions were required. No perinephric drains were utilized. No patient received inpatient postoperative narcotics. Two patients received inpatient postoperative Ketorolac. Three patients received inpatient postoperative Acetaminophen. One patient was discharged on the same day as surgery, two patients were discharged the day after surgery, and one patient was discharged on postoperative day 2. Median follow-up was 9.9 months (range 6.2e19.1 months). No postoperative complications were noted. Postoperative renal ultrasound demonstrated successful resection of diseased renal moieties, without perinephric fluid collections, in all patients. Postoperative nuclear renograms were not performed in any patient, as there was no clinical indication to perform the study.
Discussion Pediatric laparoscopic urological surgery continues to advance as more sophisticated minimally invasive options are sought in children. The feasibility, safety, and efficacy associated with laparoscopic surgery have been well documented in previous pediatric studies that compared laparoscopic and open methods [10e14]. Advances in laparoscopic techniques and equipment have led to the emergence of LESS surgery. This pioneering technique offers several potential advantages compared with Table 1
Patient characteristics.
Patient Sex (n)
Age Weight Height Surgical (mo) (kg) (cm) indication
1
Female
2.5
6.1
60
2
Male
5.1
7.4
66
3
Male
7.2
8.1
67
4
Female 16.4 12.6
85.1
Operative Length Postoperative Postoperative Follow-up Complications time of stay ketorolac acetaminophen (mo) (min) (d) used used
Obstructed 112 RUP with ureterocele Obstructed 140 RUP with ectopic ureter Primary RLP 180 UPJO and VUR Obstructed 97 RUP with ectopic ureter
1
Yes
Yes
9.4
0
0
No
No
10.4
0
2
No
Yes
6.2
0
1
Yes
Yes
19.1
0
Note. RUP Z Right upper pole; RLP Z Right lower pole; UPJO Z Ureteropelvic junction obstruction; VUR Z Vesicoureteral reflux.
Please cite this article in press as: Bansal D, et al., Pediatric laparo-endoscopic single site partial nephrectomy: Feasibility in infants and small children for upper urinary tract duplication anomalies, Journal of Pediatric Urology (2014), http://dx.doi.org/10.1016/ j.jpurol.2014.01.025
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D. Bansal et al. Table 2
Preoperative imaging.
Patient (n)
Preoperative Tc-99m-MAG3
Preoperative voiding cystourethrogram
Preoperative renal ultrasound
1
RUP/RLP/left split renal function: 0/35/65 Poorly functioning obstructed RUP RUP/RLP/left: 9.5/43.5/47 Poorly functioning obstructed RUP RUP/RLP/left: 45/0/55 Poorly functioning obstructed RLP RUP/RLP/left kidney: 2/47/51 Poorly functioning obstructed RUP
Large right ureterocele No VUR
RUP hydroureteronephrosis with large ureterocele
Bilateral grade 1 VUR (only distal ureters visualized) RLP VUR
RUP hydroureteronephrosis
No VUR
RUP hydroureteronephrosis
2 3 4
RLP hydronephrosis and scarring
Note. RUP Z Right upper pole; RLP Z Right lower pole; VUR Z Vesicoureteral reflux.
surgery in the pediatric population. The smaller abdominal working spaces in children, especially infants, can hinder the adoption of this approach. The potential for a steep learning curve and opinions of limited patient benefit may prevent the widespread use of pediatric LESS surgery. A high level of experience and skill with MIS may allow for a shortened learning curve for pediatric LESS surgery. Technical challenges include internal and external instrument clashing, difficult camera angles, lack of triangulation, and proper coordination between the assistant driving the camera and the surgeon. Hand collisions may be reduced by the use of different length and long laparoscopic instruments. Pre-bent and flexible instruments provide the ability to overcome challenges from a single port entry, but their benefit may not be realized in the smallest working spaces. Although not utilized in this series, some surgeons mitigate a single skin incision with multiple fascia incisions as a variation of LESS. Although not directly assessed in this study, cosmesis may be improved with the use of specific single port devices, such as the Olympus TriPort, which allows for placement using a 10e15-mm umbilical incision, instead of a 25-mm incision required with other available access ports. It may also be “scarless” compared with an open flank incision, which is commonly performed in infants and small children. An objective assessment comparing the cosmesis after LESS PN and conventional laparoscopic PN or retroperitoneoscopic PN is warranted to better define the role of MIS for PN in pediatric upper urinary tract duplication anomalies. While the present study is novel in presenting the first cases of infant LESS PN for upper urinary tract duplication anomalies, it has limitations. The small sample size precluded any definitive conclusions regarding the potential benefits compared with conventional transperitoneal laparoscopic, retroperitoneoscopic, robotic-assisted laparoscopic, and open surgery. More robust experiences and comparative studies are needed to better define the role of pediatric LESS PN as an emerging technique for MIS, including family preferences, value, costs, and surgeon ergonomics, as well as more traditional surgical outcomes.
Conclusions LESS PN is technically feasible, safe, and effective for upper urinary tract duplication anomalies in infants and
small children. The technique warrants further evaluation to better define its role in this patient population.
Conflict of interest None.
Funding None.
References [1] Clayman RV, Kavoussi LR, Soper NJ, Dierks SM, Meretyk S, Darcy MD, et al. Laparoscopic nephrectomy: initial case report. J Urol 1991;146:278e82. [2] Kim C, McKay K, Docimo SG. Laparoscopic nephrectomy in children: systematic review of transperitoneal and retroperitoneal approaches. Urology 2009;73:280e4. [3] Lee RS, Retik AB, Borer JG, Diamond DA, Peters CA. Pediatric retroperitoneal laparoscopic partial nephrectomy: comparison with an age matched cohort of open surgery. J Urol 2005; 174:708e11. [4] White WM, Haber GP, Goel RK, Crouzet S, Stein RJ, Kaouk JH. Single-port urological surgery: single-center experience with the first 100 cases. Urology 2009;74:801e4. [5] 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. [6] Kaouk JH, Goel RK, White MA, White WM, Autorino R, Haber GP, et al. Laparoendoscopic single-site radical cystectomy and pelvic lymph node dissection: initial experience and 2-year follow-up. Urology 2010;76:857e61. [7] White MA, Autorino R, Spana G, Laydner H, Hillyer SP, Khanna R, et al. Robotic laparoendoscopic single-site radical nephrectomy: surgical technique and comparative outcomes. Eur Urol 2011;59:815e22. [8] Rane A, Rao P, Bonadio F. Single port laparoscopic nephrectomy using a novel laparoscopic port (R-Port) and evolution of single laparoscopic port procedure (SLIPP). J Endourol 2007; 21. A-287. [9] Kaouk JH, Palmer JS. Single-port laparoscopic surgery: initial experience in children for varicocelectomy. BJU Int 2008;102: 97e9.
Please cite this article in press as: Bansal D, et al., Pediatric laparo-endoscopic single site partial nephrectomy: Feasibility in infants and small children for upper urinary tract duplication anomalies, Journal of Pediatric Urology (2014), http://dx.doi.org/10.1016/ j.jpurol.2014.01.025
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Pediatric laparo-endoscopic single site partial nephrectomy [10] Hamilton BD, Gatti JM, Cartwright PC, Snow BW. Comparison of laparoscopic versus open nephrectomy in the pediatric population. J Urol 2000;163:937e9. [11] Mei H, Pu J, Yang C, Zhang H, Zheng L, Tong Q. Laparoscopic versus open pyeloplasty for ureteropelvic junction obstruction in children: a systematic review and meta-analysis. J Endourol 2011;25:727e36. [12] Polok M, Chrzan R, Veenboer P, Beyerlein S, Dik P, Klijn A, et al. Nondismembered pyeloplasty in a pediatric population: results of 34 open and laparoscopic procedures. Urology 2011; 78:891e4. [13] Raman JD, Bagrodia A, Cadeddu JA. Single-incision, umbilical laparoscopic versus conventional laparoscopic nephrectomy: a comparison of perioperative outcomes and short-term measures of convalescence. Eur Urol 2009;55:1198e204. [14] Robinson BC, Snow BW, Cartwright PC, De Vries CR, Hamilton BD, Anderson JB. Comparison of laparoscopic versus open partial nephrectomy in a pediatric series. J Urol 2003; 169:638e40. [15] Park Y,H, Kang MY, Jeoung MS, Choi H, Kim HH. Laparoendoscopic single-site nephrectomy using a homemade single-port device for single-system ectopic ureter in a child: initial case report. J Endourol 2009;23:833e5. [16] Bayazit Y, Aridogan IA, Abat D, Satar N, Doran S. Pediatric transumbilical laparoendoscopic single-site nephroureterectomy: initial report. Urology 2009;74:1116e9.
5 [17] Jeon HG, Kim DS, Jeoung HB, Han SW, Hong CH, Im YJ, et al. Pediatric laparoendoscopic single-site partial nephrectomy: initial report. Urology 2010;76:138e41. [18] Tam YH, Pang KK, Tsui SY, Wong YS, Wong HY, Mou JW, et al. Laparoendoscopic single-site nephrectomy and heminephroureterectomy in children using standard laparoscopic setup versus conventional laparoscopy. Urology 2013;82:430e6. [19] Cindolo L, Berardinelli F, Gidaro S, Schips L. Laparoendoscopic single-site partial nephrectomy without ischemia. J Endourol 2010;24:1997e2002. [20] Greco F, Autorino R, Rha KH, Derweesh I, Cindolo L, Richstone L, et al. Laparoendoscopic single-site partial nephrectomy: a multi-institutional outcome analysis. Eur Urol 2013;64:314e22. [21] Bazzi WM, Stroup SP, Kopp RP, Cohen SA, Sakamoto K, Derweesh IH. Comparison of laparoendoscopic single-site and multiport laparoscopic radical and partial nephrectomy: a prospective, nonrandomized study. Urology 2012;80:1039e45. [22] Han WK, Kim DS, Jeon HG, Jeong W, Oh CK, Choi KH, et al. Robot-assisted laparoendoscopic single-site surgery: partial nephrectomy for renal malignancy. Urology 2011;77:612e6. [23] Kaouk JH, Goel RK. Single-port laparoscopic and robotic partial nephrectomy. Eur Urol 2009;55:1163e9. [24] Rais-Bahrami S, George AK, Montag S, Okhunov Z, Richstone L. Laparoendoscopic single-site (LESS) partial nephrectomy short-term outcomes. BJU Int 2013;111:264e70.
Please cite this article in press as: Bansal D, et al., Pediatric laparo-endoscopic single site partial nephrectomy: Feasibility in infants and small children for upper urinary tract duplication anomalies, Journal of Pediatric Urology (2014), http://dx.doi.org/10.1016/ j.jpurol.2014.01.025
MODEL
Journal of Pediatric Urology (2014) xx, 1e5
Pediatric laparo-endoscopic single site partial nephrectomy: Feasibility in infants and small children for upper urinary tract duplication anomalies D. Bansal, N.G. Cost, C.M. Bean, P.H. Noh* Division of Pediatric Urology, Cincinnati Children’s Hospital Medical Center, 3333 Burnet Avenue, ML 5037, Cincinnati, OH, USA Received 30 September 2013; accepted 24 January 2014
KEYWORDS Partial nephrectomy; Pediatrics; Laparoendoscopic single site; Minimally invasive surgery; Hydroureteronephrosis; Upper urinary tract duplication
Abstract Objective: To assess the feasibility and outcomes of laparo-endoscopic single site (LESS) partial nephrectomy (PN) in infants and small children for upper urinary tract duplication anomalies. Materials and methods: The medical records of all patients undergoing LESS PN at a single pediatric institution were retrospectively reviewed for patient demographics, perioperative details, and outcomes. A cystoscopy was initially performed to place an externalized catheter into the ureter of the ipsilateral normal renal moiety. An Olympus TriPort, an Olympus Endoeye flexible tip laparoscope, standard 3- or 5-mm instrumentation, and a LigaSure Blunt were utilized. Results: Four children (two boys, two girls) underwent LESS PN. Three patients underwent upper pole PN and one underwent lower pole PN. All procedures were performed for poorly functioning obstructed renal moieties (one ureterocele, one ureteropelvic junction obstruction and vesicoureteral reflux, and two ectopic ureters). Median age was 6.2 months (range 2.5e16.4 months). Median weight was 7.7 kg (range 6.1e12.6 kg). Median operative time was 126 min (range 97e180 min). No patient received inpatient postoperative narcotics. Median followup was 9.9 months (range 6.2e19.1 months). No postoperative complications were noted. Postoperative renal ultrasound demonstrated successful resection in all patients. Conclusions: LESS PN is technically feasible, safe, and effective for upper urinary tract duplication anomalies in infants and small children. ª 2014 Journal of Pediatric Urology Company. Published by Elsevier Ltd. All rights reserved.
Abbreviations: MIS, Minimally invasive surgery; LESS, Laparoendoscopic single site; PN, Partial nephrectomy; HN, Heminephroureterectomy. * Corresponding author. Tel.: þ1 513 636 4975; fax: þ1 513 636 6753. E-mail addresses: [email protected], [email protected] (P.H. Noh). http://dx.doi.org/10.1016/j.jpurol.2014.01.025 1477-5131/ª 2014 Journal of Pediatric Urology Company. Published by Elsevier Ltd. All rights reserved.
Please cite this article in press as: Bansal D, et al., Pediatric laparo-endoscopic single site partial nephrectomy: Feasibility in infants and small children for upper urinary tract duplication anomalies, Journal of Pediatric Urology (2014), http://dx.doi.org/10.1016/ j.jpurol.2014.01.025
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MODEL
2
Introduction The first reported use of laparoscopy for extirpative renal surgery was by Clayman et al. in 1991 [1]. Since then, laparoscopic techniques have been widely adopted within urology. Laparoscopic surgery is now commonly performed for many pediatric urologic conditions. Pediatric patients undergoing laparoscopic extirpative renal surgery have experienced shorter hospital stays, decreased pain medication requirements, and the potential for improved cosmesis [2,3]. Urologists have made significant advances in minimally invasive surgery (MIS). Efforts have continued to further minimize surgical morbidity and improve the postoperative cosmetic outcome to a virtually scar-free appearance. This evolution has led to the introduction of laparo-endoscopic single site (LESS) surgery. This innovative technique accesses the abdominal cavity using a single umbilical incision, through which different laparoscopic instruments are introduced in order to perform a multitude of extirpative and reconstructive surgical procedures. Ablative and reconstructive procedures that can be performed via conventional or robot-assisted laparoscopy have been successfully accomplished using LESS techniques [4e7]. The first two cases of single port surgery in urology were simple nephrectomy and ureterolithotomy performed by Rane et al. in 2007 [8]. Kaouk and Palmer [9] reported the first LESS surgery in three children for varicoceles in 2007. However, there are limited reports of LESS surgery performed in children. To our knowledge, we present the first experience of LESS partial nephrectomy (PN), including infants less than 1 year of age, for upper urinary tract duplication anomalies. This retrospective, descriptive, nonrandomized study was performed to assess the feasibility and outcomes of LESS PN in infants and small children for upper urinary tract duplication anomalies.
Materials and methods The medical records of all children who underwent LESS PN at a single pediatric institution from January 2012 to February 2013 were retrospectively reviewed. Chart review was performed after institutional review board approval. LESS surgery was introduced at our hospital in September 2010. Pediatric LESS PN was offered from January 2012. No patients undergoing LESS PN were excluded. All patients underwent a preoperative renal ultrasound. Preoperative voiding cystourethrograms and diuretic renal scans were performed. Indication for operative intervention included poor function of an obstructed renal moiety in upper urinary tract duplication anomalies. A cystoscopy was initially performed to place an externalized catheter into the ureter of the ipsilateral normal renal moiety, which was removed at the end of the laparoscopic procedure. The ureteral catheter was placed to help identify the normal ureter and prevent injury during the procedure. All procedures were performed via a transperitoneal approach through a single umbilical surgical site for obstructed upper or lower pole renal moieties. Data included age, weight, operative time, blood loss, drain utilization, length of hospital stay, postoperative analgesics, complications, and length of the follow-up period. Operative time was recorded as the
D. Bansal et al. initiation of skin incision until the end of skin closure. Operative time did not include cystoscopy, which was approximately 5 min for ureteral catheter placement. Patient repositioning for the laparoscopic procedure was typically another 10e15 min.
Surgical technique LESS PN was performed with an Olympus Endoeye (Tokyo, Japan) flexible tip laparoscope, Olympus TriPort, standard 3- or 5-mm instrumentation, and a 5-mm LigaSure Blunt (Covidien, Dublin, Ireland). The Olympus Endoeye is a 5-mm flexible tip laparoscope that delivers a 100-degree angulation and an 85-degree field of view. The first-generation Olympus TriPort is a multi-channel single port device that is placed via an open technique. Patients were placed in flank position. Access was obtained via a midline, full-length, unmeasured, umbilical incision, which was based on the appearance of the skin of the umbilical ring, estimated at 1.5e2.0 cm. The fascia was opened under direct vision. The Olympus TriPort and Endoeye were introduced. Standard 3- or 5-mm instruments were utilized. Sharp and blunt dissection was employed to open the posterior peritoneum and expose the retroperitoneal space. A percutaneous Prolene holding suture was placed through the diseased renal parenchyma. The upper pole was approached and exposed primarily for diseased upper pole moieties. The LigaSure Blunt was used to control the renal vessels of the involved moiety and perform the majority of the dissection. The upper pole ureter was mobilized cranial to the renal hilum for diseased upper pole moieties. The lower pole was approached primarily for the case with ureteropelvic junction obstruction. The involved renal pelvis and ureter were mobilized and used as a handle for traction and exposure. The diseased renal parenchyma was amputated using the LigaSure Blunt. The avascular plane was identified and followed, between the upper and lower renal poles. Subsequently, redundant ureter was mobilized and amputated without violating the distal common sheath of the duplicated ureters. The distal ureteral stumps of the ectopic ureters, ureterocele, and the ureteropelvic junction obstruction and vesicoureteral reflux were left open, sealed with the LigaSure Blunt, and ligated with 0-polydioxanone Endoloops, respectively. The specimen was removed intact through the single port trocar site without extension of the skin incision. The umbilical fascia was closed with interrupted 3-0 Vicryl. Local anesthesia was utilized for the umbilical incision. Regional blocks were administered on an individual basis, through shared decision-making between the surgeon, anesthesiologist, and family. Postoperative inpatient analgesia included Ketorolac and Acetaminophen administered in a non-uniform manner. Success was defined as absence of diseased renal moiety on postoperative renal ultrasounds.
Results During the study period, four patients (two boys, two girls) underwent LESS PN. Three patients underwent right upper pole PN and one underwent right lower pole PN. Three of the four (75%) patients were infants. A single surgeon
Please cite this article in press as: Bansal D, et al., Pediatric laparo-endoscopic single site partial nephrectomy: Feasibility in infants and small children for upper urinary tract duplication anomalies, Journal of Pediatric Urology (2014), http://dx.doi.org/10.1016/ j.jpurol.2014.01.025
+
MODEL
Pediatric laparo-endoscopic single site partial nephrectomy
3 traditional laparoscopy, including a reduction in the number of trocar ports with the potential for improved cosmesis, decreased morbidity, and lower analgesic requirements [5,13]. Although experience with LESS surgery in adult urology has been increasing, evidenced by the growing number of reports in the literature, there is a paucity of reports on LESS surgery in pediatric urology. In 2007, Kaouk and Palmer [9] reported the first use of the LESS technique in three patients undergoing varicocelectomy. Park et al. [15] reported the first pediatric LESS nephrectomy for a single system ectopic ureter. Desai et al. [5] first reported LESS pyeloplasty to treat primary ureteropelvic junction obstruction in a 10-year-old. Bayazit et al. [16] first reported LESS nephroureterectomy in a 10-year-old girl due to end-stage reflux nephropathy. Pediatric LESS PN has been reported in a case report for a girl with a benign renal mass [17], and a case series of children undergoing nephrectomy and heminephrectomy [18]. More commonly found are published reports of LESS PN in adults [19,20]. To our knowledge, we present the first experience of LESS PN including infants for upper urinary tract duplication anomalies. We performed LESS PN in children ranging in age from 2.5 to 16.4 months. In this population, LESS PN was feasible, safe, and effective, with similar perioperative parameters to that reported by Jeon et al. [17]. There were no conversions in our series, and operative time was shorter in our cohort than that reported by Tam et al. [18]. A vital assessment with any new innovation is monitoring of patient safety. In the present series, all procedures were technically successful without complications, conversions to open or conventional laparoscopic surgery, need for accessory instrument sites, or use of blood transfusions. The transperitoneal approach provided a virtually scarless result because the surgical incision was hidden in the umbilicus. Compared with previous adult reports of LESS PN, lower complication and conversion rates were noted in our study [21e24]. Although surgical outcomes were encouraging in our study, there still remain challenges with performing LESS
performed all LESS procedures. Clinical data for all patients are shown in Table 1. Three of four (75%) cases were found with antenatal ultrasound. The patient with an obstructed right upper pole moiety and ureterocele presented with a febrile urinary tract infection. Preoperative imaging results are shown in Table 2. Median age at surgery was 6.2 months (range 2.5e16.4 months). Median weight was 7.7 kg (range 6.1e12.6 kg). Median height was 66.5 cm (range 60.0e85.1 cm). Median operative time was 126 min (range 97e180 min). There was no significant blood loss, intraoperative complications, or conversions to open or conventional laparoscopy during any procedure. No blood transfusions or accessory incisions were required. No perinephric drains were utilized. No patient received inpatient postoperative narcotics. Two patients received inpatient postoperative Ketorolac. Three patients received inpatient postoperative Acetaminophen. One patient was discharged on the same day as surgery, two patients were discharged the day after surgery, and one patient was discharged on postoperative day 2. Median follow-up was 9.9 months (range 6.2e19.1 months). No postoperative complications were noted. Postoperative renal ultrasound demonstrated successful resection of diseased renal moieties, without perinephric fluid collections, in all patients. Postoperative nuclear renograms were not performed in any patient, as there was no clinical indication to perform the study.
Discussion Pediatric laparoscopic urological surgery continues to advance as more sophisticated minimally invasive options are sought in children. The feasibility, safety, and efficacy associated with laparoscopic surgery have been well documented in previous pediatric studies that compared laparoscopic and open methods [10e14]. Advances in laparoscopic techniques and equipment have led to the emergence of LESS surgery. This pioneering technique offers several potential advantages compared with Table 1
Patient characteristics.
Patient Sex (n)
Age Weight Height Surgical (mo) (kg) (cm) indication
1
Female
2.5
6.1
60
2
Male
5.1
7.4
66
3
Male
7.2
8.1
67
4
Female 16.4 12.6
85.1
Operative Length Postoperative Postoperative Follow-up Complications time of stay ketorolac acetaminophen (mo) (min) (d) used used
Obstructed 112 RUP with ureterocele Obstructed 140 RUP with ectopic ureter Primary RLP 180 UPJO and VUR Obstructed 97 RUP with ectopic ureter
1
Yes
Yes
9.4
0
0
No
No
10.4
0
2
No
Yes
6.2
0
1
Yes
Yes
19.1
0
Note. RUP Z Right upper pole; RLP Z Right lower pole; UPJO Z Ureteropelvic junction obstruction; VUR Z Vesicoureteral reflux.
Please cite this article in press as: Bansal D, et al., Pediatric laparo-endoscopic single site partial nephrectomy: Feasibility in infants and small children for upper urinary tract duplication anomalies, Journal of Pediatric Urology (2014), http://dx.doi.org/10.1016/ j.jpurol.2014.01.025
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MODEL
4
D. Bansal et al. Table 2
Preoperative imaging.
Patient (n)
Preoperative Tc-99m-MAG3
Preoperative voiding cystourethrogram
Preoperative renal ultrasound
1
RUP/RLP/left split renal function: 0/35/65 Poorly functioning obstructed RUP RUP/RLP/left: 9.5/43.5/47 Poorly functioning obstructed RUP RUP/RLP/left: 45/0/55 Poorly functioning obstructed RLP RUP/RLP/left kidney: 2/47/51 Poorly functioning obstructed RUP
Large right ureterocele No VUR
RUP hydroureteronephrosis with large ureterocele
Bilateral grade 1 VUR (only distal ureters visualized) RLP VUR
RUP hydroureteronephrosis
No VUR
RUP hydroureteronephrosis
2 3 4
RLP hydronephrosis and scarring
Note. RUP Z Right upper pole; RLP Z Right lower pole; VUR Z Vesicoureteral reflux.
surgery in the pediatric population. The smaller abdominal working spaces in children, especially infants, can hinder the adoption of this approach. The potential for a steep learning curve and opinions of limited patient benefit may prevent the widespread use of pediatric LESS surgery. A high level of experience and skill with MIS may allow for a shortened learning curve for pediatric LESS surgery. Technical challenges include internal and external instrument clashing, difficult camera angles, lack of triangulation, and proper coordination between the assistant driving the camera and the surgeon. Hand collisions may be reduced by the use of different length and long laparoscopic instruments. Pre-bent and flexible instruments provide the ability to overcome challenges from a single port entry, but their benefit may not be realized in the smallest working spaces. Although not utilized in this series, some surgeons mitigate a single skin incision with multiple fascia incisions as a variation of LESS. Although not directly assessed in this study, cosmesis may be improved with the use of specific single port devices, such as the Olympus TriPort, which allows for placement using a 10e15-mm umbilical incision, instead of a 25-mm incision required with other available access ports. It may also be “scarless” compared with an open flank incision, which is commonly performed in infants and small children. An objective assessment comparing the cosmesis after LESS PN and conventional laparoscopic PN or retroperitoneoscopic PN is warranted to better define the role of MIS for PN in pediatric upper urinary tract duplication anomalies. While the present study is novel in presenting the first cases of infant LESS PN for upper urinary tract duplication anomalies, it has limitations. The small sample size precluded any definitive conclusions regarding the potential benefits compared with conventional transperitoneal laparoscopic, retroperitoneoscopic, robotic-assisted laparoscopic, and open surgery. More robust experiences and comparative studies are needed to better define the role of pediatric LESS PN as an emerging technique for MIS, including family preferences, value, costs, and surgeon ergonomics, as well as more traditional surgical outcomes.
Conclusions LESS PN is technically feasible, safe, and effective for upper urinary tract duplication anomalies in infants and
small children. The technique warrants further evaluation to better define its role in this patient population.
Conflict of interest None.
Funding None.
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Please cite this article in press as: Bansal D, et al., Pediatric laparo-endoscopic single site partial nephrectomy: Feasibility in infants and small children for upper urinary tract duplication anomalies, Journal of Pediatric Urology (2014), http://dx.doi.org/10.1016/ j.jpurol.2014.01.025
