Dialogues in Pediatric Urology - Ciruroped.comThe upper pole ureter is used as a handle to...

An official publication of the Society for Pediatric UrologyRichard M. Ehrlich, M.D., Founding Editor / William J. Miller, Founding Publisher

Dialogues in

Pediatric Urology

FROM THE EDITORAnthony A. Caldamone, M.D.

Volume 30, Number 1October, 2008

FROM THE GUEST EDITOR

Laparoscopic Pediatric Urologic Surgery

GUEST EDITOR: Francisco T. Dénes, M.D.

São Paulo University Medical SchoolSão Paulo, Brazil

PARTICIPANTS:

Alaa El-Ghoneimi, M.D., Ph.D.

Lísias Nogueira Castilho, M.D.

Fabiano André Simões, M.D.

Edison D. Schneider-Monteiro, M.D.

Berenice B. Mendonca, M.D.

Miguel Srougi, M.D.

Ricardo Jordão Duarte, M.D.

Lílian Maria Cristofani, M.D.

Mario Riquelme, M.D.

Arturo. Aranda, M.D.

Job Chacko, M.D.

Ricardo González, M.D.

Kimihiko Moriya M.D.

Walid A. Farhat M.D.

Carlo Camargo Passerotti, M.D., Ph.D.

Craig Andrew Peters, M.D.

Editor: Anthony A. Caldamone, M.D.

Associate Editors: Earl Y. Cheng, M.D.

Martin A. Koyle, M.D.

Editorial Board: Sami Arap, M.D.Marc Cendron, M.D.

Terry W. Hensle, M.D.David B. Joseph, M.D.

Pierre Mouriquand, M.D.Lane S. Palmer, M.D.

Saburou Tanikaze, M.D.Elizabeth B. Yerkes, M.D.

Managing Editor: Lorraine M. O’Grady

Francisco T. Dénes, M.D., São Paulo University Medical School,São Paulo, Brazil

As in adult urologic surgery, laparoscopic procedures have advanced to a high degree ofproficiency in pediatric urologic surgery, both in ablative and reconstructive surgery.Laparoscopic pediatric urologic surgery is here to stay, and the pediatric urologists are nowfaced with the need to hone their surgical skills, due to the interest and even demand for suchprocedures.

As Guest Editor, I invited several specialists from different parts of the world to presenttheir experience in distinct and innovative laparoscopic techniques in the field of pediatricurology, hoping that it would stimulate the interest of those who are beginning their profes-sional activity, as well as enrich the experience of those who are already well trained in theseprocedures. Although this issue does not include all the possible surgeries and techniques in thefield, those presented are frequent procedures in our daily practice, and their authors haveundisputed expertise in their topics. I sincerely hope that all readers can enjoy reading this issueand learn something from it.

Society for Pediatric Urology

At a meeting of the Society for Pediatric Urology in the early 1990’s, Rick Ehrlich made apresentation on the use of laparoscopy for the diagnostic and therapeutic management of thenonpalpable testis. This was one of the first presentations that I had heard on the application ofnoninvasive technology in pediatric urology. In fact, history will show that the pediatric urol-ogy led the way in the application of laparoscopic technology. When I finally adopted Rick’srecommendations, both adult urologists and general surgeons at my institution were anxious tocome to the OR and watch this new technology and practice.

What Francis Dénes and his contributors have demonstrated for us in this issue of DPU ishow far this technology has advanced within our own subspecialty. The contributors to thisissue have been on the forefront of this technology, continuing to push the envelope, but as youwill appreciate, continuing to evaluate the results objectively as new techniques become adapted.What we have learned in pediatric urology is that the risk-benefit ratio for this technology inchildren is not always as obviously favorable as in the adult population. Therefore, a morecritical appraisal of these new technologies is necessary to provide data. Comparative studieswill be the ultimate endorsement. Each of these contributors imply that the limitation in theapplication of the technologies is not the size of the patient nor the instrumentation, but thecommitment to overcome the steep learning curve which requires both focus and time.

Rick Erhrlich concluded his landmark presentation with a very simple slide, white on blackthe slide stated: “You are either the steamroller or the road.” You have the choice.

900 Cummings Center Suite 221-U Beverly, Massachusetts 01915 USATel: (978) 927-8330 Fax: (978) 524-8890 www.spuonline.org

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Dialogues in Pediatric Urology October, 2008

Laparoscopic Partial Nephrectomy in ChildrenAlaa El-Ghoneimi, M.D., Ph.D., Professor, University Paris VII

Head of Department of Pediatric Surgery and Urology, Robert Debré University Hospital, Paris, France

(continued on next page)

Partial nephrectomy is usually done in children to remove a non-functioning upper or lower pole secondary to complicated duplexanomalies of the kidney. The usual pathology of the upper pole is ob-struction associated with a ureterocele or incontinence secondary to anectopic ureter. The usual pathology in the lower pole is reflux and lessfrequently obstruction at the UPJ with loss of function. Laparoscopicpartial nephrectomy is technically more demanding than total nephre-ctomy. These procedures can be performed using a retroperitoneal ortransperitoneal approach. Laparoscopic techniques are well suited tothis procedure, with the benefits of perfect global exposure to theanatomy of the full kidney and its vascularity without the need to mo-bilize the remaining part of the kidney. Another advantage is that thereis no need for a second inguinal incision to excise the distal ureter. Ourpreference is the retroperitoneal approach, as it provides a posterioraccess to the kidney without dissecting the main renal pedicle, an un-avoidable step during the transperitoneal anterior approach. Retroperi-toneal access can be achieved either posteriorly in a prone position orin a lateral decubitus position. Borzi compared the two approaches andfound that the lateral approach creates more inferomedial space, givesbetter access to ectopic kidneys, and allows for a complete ureterec-tomy in all cases.1

Specific Important Technical Points of Retroperitoneal PartialNephrectomy

We routinely use the lateral retroperitoneal approach as previouslydescribed (Fig. 1 and 2).2 The upper pole ureter is identified at thelower pole of the kidney, and dissected very close to its wall to avoidinjury to the vascular supply of the lower pole ureter. We find it help-ful to ligate the proximal ureter before cutting it, so the proximal

ureter remains dilated facilitating the dissection of the upper pole.Because the exposure is posterior, contrary to the transperitoneal ante-rior approach, the upper pole ureter is lifted off the vessels by bluntdissection superiorly. The upper pole ureter is used as a handle to fa-cilitate this part of dissection. The plane between the dilated upperpole pelvis and the lower pole parenchyma is easily identifiable byblunt dissection until the edges of the thin parenchyma of the uppermoiety are recognized. At this step, the upper pole vessels are identi-fied running from the aorta or the renal vessels to the upper pole paren-chyma. They are either clipped or coagulated depending on their size.The upper pole is identified by color changes after vessel ligation andby the difference in appearance between the normal lower pole and thedilated dysplastic upper pole. The duplex system anomalies have a well-defined vascular line of demarcation between the upper and lower polesof the kidney. However, sometimes it is difficult to individualize upperpole vessels, and the parenchymal transection is started before vascu-lar control of the upper pole. Transection can be done by electrocautary,but we prefer the Harmonic scalpel with the curved jaws, as it providesa clean cut at the junction between the upper and lower poles.

To minimize mobilization of the lower pole and consequently therisk of indirect vascular trauma of the renal pedicle, the lower poleremains attached to the peritoneum during all the steps of the proce-dure. The upper pole is completely freed from peritoneal attachmentbefore transecting the parenchyma to avoid transperitoneal bowel injury.

Upper Pole Partial NephrectomyIf upper pole partial nephrectomy (UPN) is done using a

transperitoneal approach, the proximal ureter must be passed behindthe renal hilum and delivered under the vessels from above after mobi-

Figure 1: Patient positioning for right retroperitoneallaparoscopic partial nephrectomyThe patient is placed in a lateral position for younger children asshown. A lumbar support is sufficient for the exposure. The child iswrapped with 2 adhesive bands, one on the greater trocanter leveland a second on the chest to keep the child on perpendicular anglewith the table. The surgeon, assistant and scrub nurse are all on theback side of the child. The front side of the child is left free for themonitor which is placed cranial while doing the kidney dissectionand caudal to proceed for the distal ureterectomy.

Figure 2: Trocar placement for retroperitoneal access for renalsurgeryArea of trocar placement, between the last rib and the iliac crest.Retroperitoneal access is achieved through the first incision (1), 10-15mm in length, and one finger width from the lower border of the tipof the 12th rib. A second trocar (2) is inserted posteriorly in thecostovertebral angle. Third trocar (3) is inserted, in the anterior axillaryline, a finger breath from the top of the iliac crest.

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lization of the upper pole ureter. This step is technically the most diffi-cult part of the procedure and requires dissection of the lower polevessels. Identification of the upper pole vessels and parenchymaltransection are identical to the retroperitoneal approach.

Lower Pole Partial NephrectomyFor retroperitoneal lower pole partial nephrectomy (LPN), access

is the same as for the upper pole. The lower pole ureter is identifiedand followed to the lower pole pelvis to be sure of its identity. Contraryto the upper pole nephrectomy, full dissection of the lower pole vesselsis necessary before transecting the parenchyma. As the main pathol-ogy is reflux with repeated infections, the lower pole is usually re-tracted and easily distinguished from the healthy upper pole paren-chyma. The ureter should be ligated close to the bladder to avoid post-operative reflux into a long ureteral stump. The line of transection issometimes difficult in lower pole nephrectomy if associated with di-lated calyces. We often find that the calyces are deeply involved in theparenchyma of the upper pole. Currently we do insert a ureteral cath-eter in the upper pole ureter and connect it to a methylene blue sy-ringe to inject at the moment of the transection. This is also done inupper pole nephrectomy procedures if there is any doubt about thediagnosis or the absence of major dilation of the upper pole ureter. Ifthere is a leak of blue, the tear can be easily identified and sutured, andthe catheter in this case would be kept for 48 hours. This has happenedin my experience in 2 cases and both were in upper pole nephrectomy.

Results and ComplicationsOperative time is a major concern in developing a new technique

in a busy institution. We have shown that there is no difference in theoperative time between open surgery and retroperitoneal laparoscopicpartial nephrectomy. The hospital stay was significantly shorter in thelaparoscopic group compared with the open surgery group . Robinsonet al., in a prospective non-randomized study, compared costs and out-comes of laparoscopic partial nephrectomy with open surgery in chil-dren.3,4 The mean operative time in the laparoscopic and open groupswas 200.4 and 113.5 min, and the mean hospital stay was 25.5 and32.6 h, respectively. Partial nephrectomy in children remains a chal-lenging procedure even in experienced hands. Valla et al have reported37% of intraoperative complications, mainly residual perirenal collec-tions at the transection line.5 The major complication is, however, theloss of function of the remaining moiety. We have lost one kidney earlyin our experience in a 7-year old child after upper pole nephrectomy.We believe that the main surgical mistake was to free the remainingmoiety from the peritoneum increasing the risk of twisting the mainrenal pedicle. Wallis et al have reported functional loss of the remain-ing moiety in 2 children aged 6 and 7 months.6 They insist on the im-portance of following these children by DMSA renal scan and not onlyDoppler studies, which may show normal hilar blood flow. They con-cluded that in children under one year there is a higher risk for compli-cations. Leclair et al have also reported higher conversion and compli-cation rates in children under one year.7

Castellan et al compared the transperitoneal with the retroperito-neal approach.8 Four of the 5 complications (80%) were seen in pa-tients younger than one year and the authors concluded that the com-plication rate does not depend on the surgical approach, but rather onthe age of the patient. Conversion to open surgery was relatively highin this series, which reported the early experience of advancedlaparoscopic surgery (retroperitoneal or transperitoneal approaches),but recent published series are more encouraging on the feasibility and

the safety of the procedure, as Dénes et al have reported no conversionin a series of 18 partial nephrectomies.9

We have reviewed our experience with special interest in our groupof patients under one year.10 Our first patient, aged 7 yr, had early post-operative renal artery thrombosis after UPN and had total nephrec-tomy. Among the 10 UPNs done in children under one year, only onehad a complication in our first year of experience which required con-version to identify the line of parenchymal section. Three children un-der one year underwent LPN and none had complications nor requiredconversion, even for a 60 mm dilated lower pelvis in a one month oldchild. Mean operative time was 150min (120-180) for LPN, and 150min(75-180) for UPN. One child had an asymptomatic urinoma after LPNat 2 years of age. All children had a well vascularized remaining moi-ety after a mean follow up of 36 months (6-60).

ConclusionsPartial nephro-ureterectomy remains a challenging laparoscopic

procedure. The main limiting factor is the learning curve and not theage at surgery or the degree of dilatation. Nevertheless, in childrenunder one year of age, surgery should be done with great care and bythe most experienced surgeon of the team. We believe that both retro-peritoneal and transperitoneal approaches are now safely feasible withcomparable results, and recommend that the surgical teams concen-trate on and improve the technique of their choice, instead of trying tocompare approaches. It is clear from the published reports that the mainobjective is to avoid the high complication rate in the beginning of theexperience. Mentored learning of the procedure is recommended be-fore starting to proceed on one’s own. We learned from our early com-plications that some aspects are necessary to make the retroperitonealapproach easier and safer:

The technique should be standardized to reduce complications,The remaining moiety should be kept attached to peritoneum,The pathological ureter should be kept dilated by ligature at thebeginning of surgery,Retrograde insertion of ureteral catheter to allow methelyne blueinjection is necessary in cases of lower pole nephrectomy or atypicalupper pole nephrectomy.

References1. Borzi P: A comparison of the lateral and posterior retroperitoneoscopic approach forcomplete and partial nephroureterectomy in children. BJU Int, 87:517, 2001.2. El-Ghoneimi A: Laparoscopic renal surgery, In : Smith’s Textbook of Endourology, Eds.Smith A et al, BC Decker Inc, Hamilton , London, 2nd ed., 2007, pp 857-64.3. El-Ghoneimi A, Farhat W, Bolduc S, et al: Retroperitoneal laparoscopic versus openpartial nephroureterectomy in children. BJU Int, 91:532, 2003.4. Robinson BC, Snow BW, Cartwright PC, et al: Comparison of laparoscopic versus openpartial nephrectomy in a pediatric series. J Urol, 169:638, 2003.5. Valla JS, Breaud J, Carfagna L, Tursini S, Steyaert H: Treatment of ureterocele on duplexureter: upper pole nephrectomy by retroperitoneoscopy in children based on a series of 24cases. Eur Urol, 43:426, 2003.6. Wallis MC, Khoury AE, Lorenzo AJ, Pippi-Salle JL, Bagli DJ, Farhat WA: Outcomeanalysis of retroperitoneal laparoscopic heminephrectomy in children. J Urol, 175:2277,2006.7. Leclair M-D, Supply E, Vidal I, Heloury Y: Laparoscopic partial nephrectomy in infantsand children. How difficult is it ? J Pediatr Urol, 3:S76, 2007.8. Castellan M, Gosalbez R, Carmack AJ, Prieto JC, Perez-Brayfield M, Labbie A:Transperitoneal and retroperitoneal laparoscopic heminephrectomy. What approachfor which patient? J Urol. 176:2636, 2006.9. Dénes FT, Danilovic A, Srougi M: Outcome of laparoscopic upper-pole nephrectomy inchildren with duplex systems. J Endourol. 21:162, 2007.10. Badawy H, Carricaburu E, Aigrain Y, El-Ghoneimi A: Retroperitoneal laparoscopicpartial nephro-urereterectomy in infants and children: analysis of risk factors and age relatedcomplications. J Pediatr Urol, 3: S80, 2007.

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In 1992 the laparoscopic approach to the adrenal gland was firstreported.1,2 Since then, several studies have been published, establish-ing the efficiency and safety of laparoscopic adrenalectomy in adults.3,4

International experience with the laparoscopic technique for adrenaldisease in children and adolescents is limited. It began with the pio-neer Japanese experience, through a program of detection of neuro-blastoma in the newborn.5,6

Some authors presented their experience with laparoscopic adrena-lectomy in children and adolescents that had different medical indica-tions for surgery. They reported cases with primary carcinoma, cyst,teratoma, ganglioneuroma, pheochromocytoma, cortical hyperplasia,medulllary hyperplasia, nonfunctioning adenoma, virilizing adenoma,leiomyosarcoma, adrenogenital syndrome, and Cushing´s syndrome(cortical adenoma and pituitary disease).7-9 Few reports of bilateral sur-gery were registered, mostly in patients with pheochromocytoma dueto the von Hipple-Lindau syndrome. Some of these patients under-went partial adrenalectomy.10 A review of the literature published in2004 included 83 patients from several medical services, with solidtumors between 10 and 80mm (average of 40mm), most of which wereoperated transperitoneally. There was a 10% conversion rate and onlyone case was transfused. The average surgical time was 120 minutesand there were few complications.11

Most authors have a preference for the lateral transperitoneal ap-proach, which we will briefly describe. The patient is in the 45-degreelateral decubitus position. Pneumoperitoneum is established with aVeress needle. We usually use a 10mm. 0-degree optical laparoscopeinserted just below the umbilicus. The other 2 or 3 ports (5/11mm) areinserted under direct vision. On the right side, after the liver is lifted,the posterior peritoneum is incised transversely just below the liver toexpose the inferior vena cava and adrenal gland. There is no need tomobilize the colon on the right side. Dissection begins on the medialborder of the adrenal gland between it and the inferior vena cava, toidentify and ligate the main adrenal vein, which is short and enters thevena cava lateral. The adrenal vein is sectioned between clips. Dissec-tion progresses from the medial to the lateral border and from the supe-rior to the inferior border of the adrenal gland. Small vessels are cau-terized and sectioned. During the operation we avoid touching the glanddirectly with graspers and scissors to preserve its integrity and avoidhemodynamic instability, which occurs in patients with pheochromocy-toma. After dissection is complete the adrenal gland is entrapped in aplastic bag and removed intact from the abdomen through a port inci-sion. The surgical field is inspected and the ports are closed. Drains arenot placed. On the left side the colon is always mobilized. To mobilizethe left colon the peritoneum is incised on the line of Toldt from thesplenic angle to the pelvic rim. The attachments of the colon to thekidney and spleen are cauterized and sectioned. The peritoneum lat-eral to the spleen is incised to mobilize medially the spleen and pan-creas tail. After medial mobilization of the left colon, spleen and pan-creas tail, the anterior renal fascia is completely exposed and incisedjust over its medial attachment. The trunk of the left renal vein is iden-tified. The adrenal vein is identified at the superior margin of the renalvein. Dissection begins close to the left renal vein to isolate and ligatethe main adrenal vein between clips, which is sometimes difficult inlarger tumors. Dissection progresses from the medial to the lateral bor-

Adrenalectomy

der and from the superior to the inferior border of the adrenal gland.The procedure is the same for the right adrenal gland. After the adrenalgland is removed the colon is left in its anatomical position withoutsutures.

We published our pioneer Western experience in 2002, with 13patients, mean age 6.3 years, a 15.4% conversion rate and good lateresults, without postoperative complications. Average operative timein unilateral nonconverted procedures was 107 minutes (range 25 to195). Blood transfusion was required in 1 case (7.7%). Average hospi-tal stay was 5.5 days (range 1 to 17). Average postoperative followupwas 16 months (range 1 to 60). The final clinicopathological diagnosiswas virilization in 4 cases, Cushing’s syndrome in 2, pheochromocy-toma in 2, neuroblastoma in 2, Cushing’s pituitary disease in 1, ter-atoma in 1 (the first reported in the literature) and primary carcinomain 1.7

Our personal experience and an analysis of the published reports,which are few, allow us to reach the following conclusions:1. Total or partial laparoscopic adrenalectomy in children and adoles-cents is technically feasible, regardless of the patient’s age and weight.The limit of the tumor volume that can be operated through laparoscopictechnique depends on each surgeon’s experience;2. Most authors show a preference for the lateral transperitoneal ap-proach, with a conversion rate between 10 and 20%;3. This type of surgery is predominantly indicated in benign diseases,unilateral or bilateral, and in selected cases of malignant diseases, es-pecially neuroblastoma;4. The results that have been obtained thus far are as good as thosereported in adults, suggesting that the laparoscopic adrenalectomyshould be considered the gold standard of adrenal surgery in childrenand adolescents.

References 1. Gagner M , Lacroix A , Bolte E: Laparoscopic adrenalectomy in Cushing’s syndromeand pheochromocytoma . N Engl J Med, 327: 1033, 1992.2. Higashihara E , Tanaka Y , Horie S , Aruga S , Nutahara K , Homma Y , Minowada S,Aso Y: A case report of laparoscopic adrenalectomy . Nippon Hinyokika Gakkai Zasshi, 83:1130, 1992.3. Bendinelli C , Materazzi G , Puccini M , Iacconi P , Buccianti P , Miccoli P: Laparoscopicadrenalectomy. A retrospective comparison with traditional methods . Minerva Chir, 53:871, 1998.4. Castilho LN: Laparoscopic adrenalectomy – experience of 10 years. Arq Bras EndocrinolMetabol, 48: 776, 2004.5. Yamamoto H , Yoshida M , Sera Y: Laparoscopic surgery for neuroblastoma identified bymass screening . J Pediatr Surg, 31: 385, 1996.6. Nakajima K , Fukuzawa M , Fukui Y , Komoto Y , Usui N , Iiboshi Y , et al. . Laparoscopicresection of mass-screened adrenal neuroblastoma in an 8-month-old infant . Surg LaparoscEndosc, 7: 498, 1997.7. Castilho LN, Castillo OA, Dénes FT, Mitre AI, Arap S: Laparoscopic adrenal surgery inchildren. J Urol 168: 221, 2002.8. Miller KA, Albanese C, Harrison M, Farmer D, Ostlie DJ, Gittes G, Holcomb GW 3rd:Experience with laparoscopic adrenalectomy in pediatric patients. J Pediatr Surg 37: 979,2002.9. Skarsgard ED, Albanese CT: The safety and efficacy of laparoscopic adrenalectomy inchildren. Arch Surg 140: 905, 2005.10. Ludwig AD, Feig DI, Brandt ML, Hicks MJ, Fitch ME, Cass DL: Recent advances in thediagnosis and treatment of pheochromocytoma in children. Am J Surg 194: 792, 2007.11. Pampaloni E, Valeri A, Mattei R, Presenti L, Centonze N, Neri AS, Salti R, Noccioli B,Messineo A: Initial experience with laparoscopic adrenal surgery in children: is endoscopicsurgery recommended and safe for the treatment of adrenocortical neoplasms? Pediatr MedChir 26: 450, 2004.

Lísias Nogueira Castilho, M.D., Fabiano André Simões, M.D.Urologic Clinic, Pontifícia Universidade Católica, Campinas, Brazil

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Laparoscopy in Disorders of Sex DevelopmentFrancisco T. Dénes, M.D.*, Edison D. Schneider-Monteiro, M.D.**, Berenice B. Mendonca, M.D.**, Miguel Srougi, M.D.*

Hospital das Clínicas, São Paulo University, Urologic* and Endocrinologic** Clinics, São Paulo, Brazil

The correct clinical evaluation of patients with disorders of sexdevelopment (DSD) allows the identification of the primary diseaseand reduces the probability of inappropriate management regardingsex assignment. The aim is to offer the best quality of life, reconcilingstructural limitations with the functional potential of both internal andexternal genitals, aligning them as best as possible to the assigned gen-der of the patient. Due to its minimal invasive nature, absence of scars,efficacy and low morbidity, laparoscopy emerged as an optimal mo-dality for evaluation and treatment of patients with DSD. Diagnosticlaparoscopy is restricted to 46,XX DSD to differentiate 46,XX testicu-lar DSD and ovotesticular DSD in male patients with genital ambigu-ity and impalpable gonads. Therapeutic laparoscopy is more ample,being employed to remove the ductal structures and gonads that areeither incompatible with the social gender, or gonads that are non-func-tional and dysgenetic, as well as those that are malignant or presentpotential of malignant degeneration (patients carrier of Y-chromosomewith dysgenetic gonads). Associated conditions such as hernia, cryp-torchidism and urinary malformations can also be managed withlaparoscopy. The disorders of sex development conditions for whichlaparoscopy is employed are the following:

46,XX DSD: In the exceptionally virilized 46,XX patient with malegender identity, laparoscopy is indicated for the removal of the femalegonads and müllerian derivatives.

46,XY DSD: Whenever possible, 46,XY patients with an under-developed phallus and female gender identity should undergo femi-nizing genitoplasty and laparoscopic removal of intra-abdominaldysgenetic gonad or normal testis. The uterus, even when rudimentary,should be retained, since estrogen replacement at pubertal age mayinitiate menstruation. When the gender identity of the patient is male,orthophalloplasty and neourethroplasty should be performed, and thenormal testes must be secured to the scrotum by laparoscopy, with re-moval of the uterus and the vaginal component of the urogenital sinus.If the gonads are dysgenetic, they should be removed along with themüllerian structures.

46,XX Ovotesticular DSD: These patients present coexistent ova-rian and testicular tissue with variable configuration and asymmetricambiguous external genitalia. Generally, treatment is oriented towardsthe female gender role, with laparoscopic removal of the testis or thetesticular portions of the ovotestis, associated with feminization of theexternal genitalia. Patients with an enlarged phallus and/or male iden-tification can be treated with laparoscopic removal of the female go-nads and ductal structures, orchiopexy of the remnant testes, and asso-ciated masculinization of the external genitalia.

Gonadal dysgenesis: Patients with 45,X karyotype or mosaicismwith 45,X lineage associated with other cell lines with the presence ofY-chromosome may have rudimentary or streak gonads that must beremoved due to malignant potential.

OPERATIVE TECHNIQUE:No specific preoperative preparation is needed, except enema in

obstipated patients. The patient is positioned in a prone Trendelenburgposition, the arms alongside the body. The monitor should be at thefoot of the patient. When concomitant genitoplasty is planned, the geni-tal area must also be prepared and exposed. The genitalia and inguinal

regions should be re-evaluated with the pa-tient under anesthesia.Bladder catheterizationis done on the opera-tive field. Usually athree trocar approach(1 umbilical and 2iliac) is employed, withan eventual fourth su-prapubic access to mo-bilize the bladder ifnecessary.

Gonadectomy is astraightforward proce-dure, since the gonadsare easily identifiedand have an easily ac-cessible pedicle. Thepossible occurrence ofdysgenetic or neoplas-tic gonads, sometimeswith an odd appear-ance, should not beoverlooked (Figure 1).It is necessary to evalu-ate the internal in-guinal orifices, whichmay be patent. Thecontents of the in-guinal canals shouldbe explored if the in-ternal inguinal ring ispatent and gonads arenot identified in the ab-dominal cavity. A stan-dard laparoscopic or-chidopexy can be donewhen a normal testishas to be relocated tothe scrotum. In casesof agonadism, neithergonadal structure, norits vessels are found inthe abdominal cavity,but ductal structures may be present. These extend between the gonadsand the retrovesical space. In the midline, behind the bladder, it is pos-sible to identify the (hypoplastic) uterus (Figure 2). Removal of ductalstuctures is easily performed in most cases, but hysterectomy withressection of the vaginal component of the urogenital sinus may bedifficult, due to its retrovesical extension. When a short vaginal com-ponent joins the urethra above the pelvic floor, complete resection ofthe vagina can be performed entirely laparoscopically, but care must

Figure 1: Dysgenetic (“Streak”) left gonadbeing removed in a 17-year-old 46,XY DSDpatient.

Figure 2: Hysterectomy in a 3-year-old46,XX ovotesticular DSD patient.


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IntroductionVideolaparoscopy has been reported for diagnosis and staging of

pediatric solid tumors such as neuroblastoma, adrenal carcinoma andovarian teratoma. Recently, this procedure has been successfully ex-tended to the treatment of Wilms’ tumor, which comprises almost 90%of renal masses in children.

Open surgery is the classic approach for Wilms’ tumor resection,and includes a complete inspection of abdominal cavity, lymph nodesampling and radical nephrectomy without neoplastic cell spillage. Ingeneral, preoperative chemotherapy decreases tumor size and inducesthe formation of a pseudocapsule, reducing the risk of tumor rupture,therefore, enabling a safer and easier surgical resection.

Radical Nephrectomy for Pediatric Kidney TumorsRicardo Jordão Duarte, M.D., Lílian Maria Cristofani, M.D., Francisco Tibor Dénes, M.D., Miguel Srougi, M.D.

Hospital dasClínicas, São Paulo University, Urologic and Pediatric Clinics, São Paulo, Brazil

be taken not to injure the ure-thra. In patients with a longvaginal component of theurogenital sinus, thelaparoscopic dissectionshould be extended as far dis-tally as possible, close to theperineal musculature. If thevaginal wall is lacerated, itmay be difficult to remove itcompletely. In this situation,the intra-abdominal stumpmay be left open, but its in-ternal mucosal lining must beextensively cauterized as dis-tally as possible (Figure 3).The extra-abdominal orperineal vaginal segmentmust be removed by a retro-grade perineal access, usu-ally performed together withthe genitoplasty. After cauter-ization of bleeders, theretrovesical defect must beclosed with approximation ofthe peritoneal flaps. This isparticularly important whenthe vaginal dissection is com-pleted by the perineal ap-proach, in order to isolate theperitoneal cavity. In general, drainage is not necessary.

Post-operative feeding can be resumed immediately and dischargemay be in the next day, except in cases of associated genitoplasty. Whenthere is resection of the vaginal component of the urogenital sinus, it isimportant to leave the bladder catheter inserted for up to 7 days, inorder to allow an adequate urethral and retrovesical cicatrization.

Our experience with laparoscopic procedures in 67 DSD patients,aged 6 months to 47 years (mean 18.6 ys.) is summarized in Table 1. Inthis group of patients, there were no significant peri- or post-operativecomplications, no conversions, and the functional and cosmetic resultswere excellent.

Figure 3: 4-year-old patient with 46,XX DSD with male role: aand b) significant masculinization of external genitalia, c)retrograde urethrocystogram showing vaginal cavity, uterus andtubes; d) laparoscopic dissection of vaginal component ofurogenital sinus, e) removed specimen including both ovaries,uterus and vagina.

References1. Dénes FT, Mendonça BB, Arap S: Laparoscopic management of intersexual states. UrolClin North Am, 28: 31, 2001.2. Fugita O, Dénes FT: Laparoscopic gonadectomy and excision of Müllerian remmant inan adult intersex patient. Letter to the Editor. Urology, 58: 635, 20013. Dénes FT, Coccuzza MAS, Schneider Monteiro EDF, Silva FAQ, Costa EMF, MendonçaBB, Arap S: The laparoscopic management of intersex patients: the prefered approach.BJU Int, 95:863, 2005

Table 1: Clinical diagnoses andlaparoscopic procedures in 67 patients

Although the SIOP has always recommended preoperative che-motherapy, the NWTS protocols have performed surgical resection ofthe tumor as the first step of treatment. Nevertheless, the final resultsof overall and disease free survival of both groups are similar. TheBrazilian Cooperative Group for the treatment of Wilms’ tumor is com-mitted to the SIOP 2001 protocol, therefore, all our patients receivepreoperative chemotherapy, offering the opportunity to applylaparoscopic radical nephrectomy in selected cases. The procedure isindicated in unilateral non-metastatic Wilms’ tumors that present sig-nificant reduction in tumor size after chemotherapy using a four-week


7


Table 1 - Results of laparoscopic nephrectomy in children withWilms’ tumor.

Figure 4: Late post-operativeview showing excellent cosmeticappearance of abdomen.

Figure 3: Removal of kidney withthe tumor and post-operativeabdominal view.

Figure 2: Operative field andlaparoscopic vision of Wilms’ tumorduring dissection.

Figure 1: Wilms’ tumor in a 46 months old girl:abdominal CT scan before(A) and after (B)preoperative chemotherapy.

schedule ofv inc r i s t i neand actino-m y c i n - D(Figure 1). Aretrospectiveanalysis ofthe character-istics of ourpatients sub-mitted to theprocedure shows that the ratio between the tumor’s largest dimensionon the post-chemotherapy CT scan and the patient’s height ranged from0.04 to 0.096, indicating that the tumor’s dimensions of our patientswere always less than 10% of the patients’ height. We think this couldbe an useful index for helping the surgeon to consider the laparoscopicapproach in the management of this neoplasia. Tumors that remain sig-nificantly large after preoperative chemotherapy or present extensive ad-hesions to the liver, spleen or diaphragm are best treated by open surgery.We also do not recommend laparoscopic nephrectomy for tumors not ex-posed to preoperative chemotherapy, even if they are small, due to the riskof intraoperative tumor rupture and neoplastic cell spillage.

Surgical TechniqueThe patient is in a 30o con-

tralateral supine position, undergeneral anesthesia. Pneumoperi-toneum is achieved with an um-bilical puncture with the Veressneedle, and the abdominal cav-ity is insufflated to a pressure of12 mmHg. A 5-10 mm trocar isplaced infraumbilically for thecamera, a 3 mm one near thexyphoid, another 3-5 mm at theiliac fossa and a 3-5 mmsubcostally at the anterior axil-lary line, both sites according totumor location (Figure 2).

Laparoscopic evaluation of abdominal cavity is always performedin the search of metastasis. After mobilization of the colon, Gerota’sfascia is identified, as it includes a very well defined fibrous tissue(pseudocapsule) that involves the affected kidney, as result of preop-erative chemotherapy (Figure 2). The dissection is then extended tothe vessels, beginning with the vena cava on the right side and therenal vein on the left. Both the renal vein and artery are identified,dissected, ligated with polypropylene clips as proximally as possibleand sectioned. The spermatic and adrenal veins, as well as the ureter,must also be identified and sectioned on both sides, to ensure easiermobilization of the specimen. The kidney and perirenal fat are thendissected “en bloc”, and in most cases this is easily accomplished, ex-cept in cases with adhesions to the liver or diaphragm, when great caremust be taken to avoid injury. At this point, the harmonic scalpel isvery useful. After complete mobilization of the specimen, it is placedin a plastic retrieval bag introduced through a Pfannenstiel incision.Before removal of the tumor through this incision, pericaval and peri-aortic lymph node samples are also obtained. The incision and portsare closed without drains (Figure 3). In our experience with 14 pa-tients, operative time ranged from 120 to 180 minutes (average 147minutes), and the tumor was completely resected without rupture in allcases (Table 1). There were no short or long term postoperative complica-tions in our series, except two cases of prolonged ileus. No tumor relapseswere observed and the aesthetical result were very good (Figure 4).

REFERENCES1. Peters CA: Laparoscopy in pediatric urology. Curr Opin Urol 14: 67, 2005.2. Castilho LN, Castillo OA, Dénes FT, Mitre AI, Arap S. Laparoscopic adrenal surgery inchildren. J Urol 168:221, 2002.3. Spurbeck WW, Davidoff AM, Lobe TE, Rao BN, Scropp KP, Shochat SJ: Minimally invasivesurgery in pediatric cancer patients. Ann Surg Oncol 11:340, 2004.4. Duarte RJ, Dénes FT, Cristofani LM, Odone–Filho V, Srougi M: Further experience withlaparoscopic nephrectomy for Wilms’ tumour after chemotherapy. BJU Int 98:155, 2006.

Case

Side

Age

(months)

Weight of

patient

(Kg)

Height of

patient

(cm)

Specimen

dimension

(cm)

Specimen

weight

(g)

t

Surgery

(minutes)

Pathological

Stage

1 L 54 16 100 9.5x5.5 125 120 I

2 R 70 17 106 11.5x5.0 125 180 I

3 L 25 11 79 9.0x6.0 120 165 I

4 R 60 18 107 8.5x5.5 120 180 I

5 R 39 15 100 9.9x9.5 55 180 III

6 R 67 21 110 12.5x6.5 234 150 II

7 L 21 11 78 11.0x6.0 175 180 I

8 R 19 8,5 77 6.3x4.8 80 180 I

9 R 79 20 117 11.5x6.0 162 120 II

10 R 10 8 73 7.0x5.0 55 120 I

11 R 46 16,7 107 9.0x5.0 115 120 I

12 R 36 14 94 10.0x6.0 112 130 I

13 R 108 27 142 9.5x6.0 151 120 II

14 R 36 16 95 10 x 6.0 112 120 III

8


Laparoscopic Extravesical Ureteral Reimplantation (LEVUR)Mario Riquelme, M.D. and Arturo Aranda, M.D.

Christus-Muguerza Hospital, University of Monterrey, Monterrey, Mexico

The minimally invasive surgery approach for vesicoureteral re-flux (VUR) has gained acceptance and several techniques have emerged.The laparoscopic extravesical ureteral reimplantation (LEVUR) hasemerged relatively late, compared to other procedures on the urinarytract, as a very effective and safe procedure.

The most important steps are described as follows. The patient ispositioned supine and a Foley catheter is inserted. Sterile preparationis done from the xyphoid to the genital area. The surgeon’s positionshould be at the head of the patient, no matter which ureter is to betreated. Three trocars are used and the right-sided trocar should be a5mm for the harmonic scalpel (for right handed surgeons). A 30 or 45degree lens is recommended in order to obtain a better visualization ofthe postero-inferior side of the bladder.

The initial approach in females should be through the anterior surfaceof the broad ligament, with care of not cutting through the posterior sur-face of this ligament. It is necessary to incise the round ligament of theaffected side in order to reach the most inferior part of the ureter. By doingthis, there is a great increase in working area, making the operation easierand enabling a wider range of movements during the procedure.

The peritoneum is incised on the lateral side of the ureter, withgreat care to not injure the ovarian vessels that run alongside the ova-rian suspensor ligament, which has to be bluntly separated. With thismaneuver, a complete access is obtained of the now free middle anddistal thirds of the ureter. It is necessary to make sure that thevesicoureteral junction is precisely identified. In order to do so, rami of theinferior vesical artery must be identified and cauterized with the harmonicscalpel. In males, great care is necessary to avoid injury to the vas.

After completing the dissection, the ureter is placed on top of thebladder, in order to evaluate the length of detrusor to be incised. Theline of incision is demarcated with the electrocautery, which alsoachieves hemostasis. The bladder wall is held with a grasper and thena mucosa bulging incision is done in the muscle (similar to a pyloromyo-tomy) with the harmonic scalpel. Filling the bladder partially facili-tates this maneuver. The few muscle fibers that are not divided are cutusing blunt tip scissors. Also, a dissector can be used to spread themuscle fibers. Once the detrusor is divided, the mucosa is inspected andleaks are searched and sutured. In case of a small perforation, repair is notnecessary, requiring the urinary catheter in place for a longer period.

A polyester 2-0 suture, with RB-2 needle is brought into the ab-dominal cavity. With the ureter oriented towards the top of the bladder,the needle is passed through the lateral lip of the detrusor incision. Theneedle is then passed below the ureter and through the medial lip of theincision. The ureter is now pushed into the detrusor trough, and themuscle approximated by the suture above it, creating a tunnel. Intra-or extracorporeal knots are used and care is taken not to strangulate theureter. This can be assessed by intermittently checking that the ureterslides easily in the tunnel in order to avoid ureteral stenosis. Two tothree more stitches are placed with great caution, in order to preventincorporating the ureter. Assessment of a floppy detrusorrhaphy and anon-ectasic ureter is important. The ends of the round ligament areunited and the broad ligament is repaired. An immediate post-opera-tive cystogram is performed in the operating room, to confirm the ab-sence of VUR. No urinary catheter is left in place in the cases withoutmucosal perforation.

In our recently reviewed experience from January 2001 to April2008, we have operated on 42 renal units in 35 pediatric patients (28with unilateral VUR, 7 with bilateral VUR). All were II/III grade VUR.Age range is 12 to 62 months (average 48 mos.). Of the unilateral cases,4 had duplex kidneys. All the ureters were successfully reimplantedwithout postoperative stenosis. All 7 bilateral cases were repaired in asingle procedure. None of these patients presented postoperative blad-der emptying difficulty. Operative time averaged 110 minutes in uni-lateral and 180 minutes in the bilateral cases. All VUR resolved com-pletely, except in one renal unit in which the VUR improved from agrade III to a grade I. There were 4 mucosal perforations that weretreated with 72 hours of a bladder catheter. One had a voluntary re-moval of the catheter immediately after discharge, and developed anurinoma, that was managed with open exploration and repair.

Follow-up has been 0-7 years, and three patients presented uri-nary tract infection. All 4 cases with duplex kidneys and the 7 bilateral

Figure 1: Ureteral dissection shown.

Figure 2: The bladder mucosa is exposed.


9


Figure 3: Complete closure of detrusor tunnel.Figure 4: Cystoscopic view of ureteral bulge.

cases had a total VUR resolution and have had no urinary infectionduring follow up. We recommend this technique even in bilateral andduplicated collecting systems.

A recent publication that reviews the treatment of VUR by mini-mally invasive approach reports the benefits and advantages of LEVUR.This review describes worldwide experiences, including ours. Due to thishigh success rate, we believe that the LEVUR will become the surgicaltreatment of choice, place now occupied by the Cohen technique.

References1. Tsai YC, Dei Yang SS. Laparoscopic ureteral reimplantation for vesicoureteral Reflux: Amini-review. JTUA 18:75, 20072. Callewaert P. What is new in surgical treatment of vesicoureteral reflux? Eur J Pediatr166:763, 20073. Riquelme M, Aranda A, Rodriguez C. Laparoscopic extravesical transperitoneal approachfor vesicoureteral reflux. J Laparoendosc Adv Surg Tech AJun, 16:312, 20064. Lakshmanan Y, Fung LC. Laparoscopic extravesicular ureteral reimplantation forvesicoureteral reflux: recent technical advances. J Endourol., 14:589, 2000

www.worldcongresspediatricurology.org

10


We initiated our program of laparoscopic pyeloplasty at A.I. duPontHospital for Children in August, 2004 after having considerable expe-rience with laparoscopic ablative surgery in children. Initially we of-fered this approach only to children over 3 years of age and graduallyexpanded the application to all ages and to re-operative pyeloplasty.To date we have done more than 70 pediatric pyeloplasties, which pro-vide the foundation for the recommendations in the present article. Theoperations have been performed by 4 attending surgeons, often col-laborating with one another and have also been used as part of ourtraining program for pediatric urology. The laparoscopic approach hasnot in any way changed the indications for the operation.

We use the transperitoneal approach since we see no advantagesto the more cumbersome retroperitoneoscopic approach. We have notexperienced injury to abdominal viscera or postoperative complica-tions due to adhesions and feel that the improved visualization andincreased working space is beneficial in this approach.

A cystoscopy, retrograde ureteropyelo-gram and placement of adouble J stent are always performed at the beginning of the procedure.We consider the retrograde pyelogram essential to delineate the anatomyand assess the length of the abnormal ureteral segment. We find retro-grade placement of the stent more expeditious than antegrade place-ment. In children under weighing 10 kilograms or less, we use a totalbody prep to avoid re-prepping and re-positioning.

The initial access to the peritoneum is umbilical using the bluntBailez technique with a 5 mm camera port. Pneumoperitoneum is es-tablished at 8 mm of mercury for infants and small children and 12 mmin older children. We normally use 2 additional 3 mm ports; rarely in aright pyeloplasty may a 4th port for a liver retractor be necessary. Ad-ditional port placement for the left side is in the epigastrium, left of theligamentum teres, and in the hypogastrium at the level of themidclavicular line. For the right side, and for a right handed surgeon,we prefer to place the upper port to the right of the midline to betteralign the needle driver with the suture line.

The right UPJ is always approached by taking down the hepaticflexure of the colon. On the left side we use the transmesocolonic ap-proach whenever possible. We avoid dissecting the ureter excessivelyand minimize the use of cautery around it. Once the UPJ is exposed,we place 2 percutaneous traction sutures of 4-0 Prolene, 1 at the junc-tion, lateral to the ureter and one in the proximal and medial aspect ofthe pelvis. These sutures suspend the area of the anastomosis, mini-mizing the need to manipulate the tissues or suction. The pelvis is cutfirst; reduction of the pelvis is only done in cases of extreme dilatation.If a crossing vessel is present, the ureter is now transposed anterior toit. Leaving part of the pelvis attached to the ureter aids in the orienta-tion to spatulate the ureter along its lateral aspect. The spatulation shouldbe long enough to reach normal ureter with at least 1 cm margin. Theanastomosis is done with 5-0 or 6-0 Monocryl. In the past we have alsoused Vicryl and PDS. We prefer Monocryl because it does not curl, isdifficult to break and slides though the tissues easily. We prefer dyedsutures with a needle cut 8 to 10 cm with a knot at the end. We find itpreferable to introduce the needle though the 5 mm port to minimizethe chance of blunting its tip during introduction. As in open pyeloplasty,

Pediatric Laparoscopic PyeloplastyJob Chacko, M.D. and Ricardo González, M.D.

A.I.duPont Hospital for Children and Thomas Jefferson University. Wilmington, DE and Philadelphia, PA, USA

we use a running suture that starts in the posterior wall away from theapex and runs around the corner. Visualization of the critical apicalarea is easier if the suture is carried inside the real pelvis and ureter.Usually 2 sutures are needed. Prior to completing the anastomosis theposition of the stent is checked radiologically. A small silastic drainwith perforations is left in the vicinity of the anastomosis exiting throughthe port in the hypogastrium.

Post-operatively, the patients are placed on a clear liquid diet. Thefoley catheter is generally removed on post-operative day 2 and thedrain removed the next day if the drainage is low. Patients return forstent removal in 4-6 weeks in the operating room.

We recently reviewed our experience with primary laparoscopicpyeloplasty (LP). Fifty-six patients underwent LP; of these 40 weremale and 16 femalewith an average age of53.6 months and aver-age weight of 20 kilo-grams. Intraopera-tively, 51/56 (91%) hada retrogradeure te ropye logram,while 55/56 (98%) hada ureteral stent placed.The average operativetime was 249 minutes.After surgery, the aver-age hospital stay was 3days with the averagecatheter duration of 2days, and average drain duration of 3 days. The stent was removed onaverage after 39 days. Patency of the anastomosis was seen in 55/56(98%) at an average follow-up of 7 months. Complications included:redo LP for recurrence (1), nephrostomy dislodgement (1), stent re-placement (1), ileus (2), and vascular injuries treated laparoscopically(2). None of the patients required an open conversion.

We have currently adopted laparoscopic pyeloplasty as our stan-dard treatment for primary as well as redo-pyeloplasty with great suc-cess. We hope that the lessons we have learned will help decrease thelearning curve for those pediatric urologists interested in the transitionfrom open to laparoscopic pyeloplasty.

References1. Neheman A, Noh PH, Brenn R, González R. Laparoscopic urinary tract surgery in infantsweighing 6 kg or less: perioperarive considerations and comparison to open surgery. JUrol, 179 :1534, 2008.2. Neheman A, Piaggio LA , Noh PH, González R. Laparoscopic reconstructive surgery inchildren weighing ten kilograms or less: A comparison with open surgery. Journal of PediatricUrology, 2008; In Press.3. Piaggio LA, Frank-Guimond J, Barthold JS, Noh PH, Wehry M, Figueroa TH, GonzálezR. Transperitoneal laparoscopic vs open pyeloplasty in infants and children. J Urol, 178:179,2007.4. Piaggio LA, González R. Reoperative laparoscopic pyeloplasty in children. Comparisonwith open surgery. J Urol ,177:1878, 2007.

To date we have done

more than 70 pediatric

pyeloplasties, which

provide the foundation

for the recommendations

in the present article.

11


Complete Intracorporeal Laparoscopic EnterocystoplastyKimihiko Moriya M.D. and Walid A. Farhat M.D., Division of Urology.

The Hospital for Sick Children, University of Toronto, Toronto ON Canada

IntroductionDespite the widespread introduction of laparoscopic procedures

in pediatric urology, augmentation cystoplasty is still performed in anopen fashion at most institutions due to the perceived intricacy anddemanding nature. Herein we describe our technique for completeintracorporeal laparoscopic enterocystoplasty, following with a discus-sion about surrounding innovations and possible complications, basedboth on our experience and outside reports.1,2

ContraindicationsContraindications to complete intracorporeal laparoscopic

enterocystoplasty are similar to those found in an open fashion. How-ever, in addition, a history of prior major abdominal or pelvic opera-tions may also pose a contraindication, although intra-abdominal ad-hesions can be released to some extent. Minor previous procedures,such as cecostomy tube or upper abdominal surgery, are not found tobe relative contraindications.

Preoperative PreparationPoorly prepared bowel places the patient at an increased risk for a

large intraperitoneal spill and any of its potential associated seriousconsequences; therefore, full mechanical and antibiotic preoperativebowel preparation would be imperative. Although a recent report hassuggested that bowel preparation is unnecessary for cystoplasty in chil-dren3, our protocol for laparoscopic procedures involving bowel wouldbe to reduce the bacterial load as much as possible, according to thecurrent standards of care.

Surgical ProcedureThe patient is placed supine with the legs slightly apart and a Foley

catheter is inserted. We put ureteral stents to initially identify the ure-ters, thus to avoid ureteral injuries. However, since it is not an essentialprocess for laparoscopic enteroplasty, recently ureteral stents have notbeen placed. A total of three ports are placed with the configurationshown in Figure 1. In brief, a 12-mm trocar is inserted at the umbili-cus. After achieving adequate intraperitoneal pressure, a 12-mm trocarin the right upper quadrant and a 5-mm trocar in the left upper quad-rant are inserted at the mid-axillary level (Figure 1).

A premeasured 15-cm vessel loop segment is used for the estima-tion of the distance appropriately. To select the segment of bowel,

attention is paid to the distance of the loop from the ileocecal valve andthe mobility of its mesentery, which should allow for tension-free ad-vancement toward the pelvis. The points of excision are demarcatedby placement of percutaneous sutures as fixing sutures to the abdomi-nal wall using a Keith needle; providing an easy visual aid to identifythese points (Figure 2). Using the laparoscopic light, identification ofthe mesenteric vessels is made easier and mesenteric windows are thendeveloped with the assistance of the laparoscopic hemostatic cuttingdevices. The segments of bowel are transected with endoscopic gas-trointestinal anastomosis staplers (Endo-GIA), and subsequently bowelcontinuity was restored with a side-to-side anastomosis using the sta-pler device and intracorporeal free-hand sutures as in open surgery.

After the isolated ileal loop is irrigated in situ with the laparoscopicsuction irrigation with antibiotic solution, the bowel is opened on itsantimesenteric border, using the laparoscopic hemostatic cutting de-vices. The U-shaped reconfiguration of the detubularized patch isachieved by securing the apex to the anterior abdominal wall and ex-pedited by intracorporeal free-hand sutures or the use of the Endo-Stitch Autosuture device.

A running anastomosis with the bladder and detubularized ilealpatch can be achieved by either intracorporeal free-hand sutures orthe use of the Endo-Stitch Autosuture device under direct visualiza-tion. A watertight closure is then verified by irrigating with sterilesaline through the Foley catheter. Either port can then be used toadvance a closed suction drain near the anastomosis.

Technical InnovationsAs we described above, laparoscopic augmentation cystoplasty

closely mimics the time-honored open counterparts. However, ap-plication of some technical innovations is required to perform com-plete intracorporeal laparoscopic enterocystoplasty.


Figure 1: A 12-mm trocar is inserted at the umbilicus. A 12-mm trocarin the right upper quadrant and a 5-mm trocar in the left upper quadrantare inserted at the mid-axillary level.

Figure 2: Transabdominal fixating sutures are placed through theabdominal wall and the structure of interest. A) A blue suture (blackarrowheads) indicates an isolated ileal loop for augmentationcystoplasty and a white suture (white arroheads), for anastomosis. B)Both fixing sutures are secured outside the abdominal wall. Thisrelatively simple maneuver keeps the proper orientation of the ileumand the tension, and secures the anatomic structure of interest to preventkinking and twisting of the mesentery.

12


Measurement of the ileum: Since visual estimation of the bowelmay be inaccurate, a premeasured vessel loop segment to measure thelength of the ileum helps rapid and accurate estimation of the distances.

Fixing suture: At multiple points during the procedure, transab-dominal fixating sutures are advanced percutaneously (Figure 2). Thesesutures are placed through the abdominal wall and the structure of in-terest, a process that can be accomplished with a Keith needle. Thisrelatively simple maneuver keeps the proper orientation of the ileumand the tension, and secures the anatomic structure of interest to pre-vent kinking and twisting of the mesentery. This also has the advan-tages of easy relocation, depending on changes in the angle of dissec-tion, as well as allowing the surgeon to complete the procedure withfewer trocars. Furthermore, because the need for an assistant to helpwith positioning and exposing structures during the case is not neces-sary, the use of these anchoring sutures provides a greater degree ofmovement, not only inside the abdominal cavity, but also around thepatient, an important consideration in pediatric patients.

Suturing: Although intensive suturing and intracorporeal tying arerequired in this surgery, suturing and tying are often the most difficultand time-consuming procedures in laparoscopy. The Endo-StitchAutosuture might be helpful in creating the ileal patch and suturing thepatch to the bladder. However, those procedures can be achieved ad-equately by free-hand suturing of experienced hands. Therefore, ex-tensive experience with laparoscopy is necessary before attemptinglaparoscopic augmentation cystoplasty.

Possible ComplicationsGeneral complications related to laparoscopy, such as injury from

Veress needle or trocar insertion, port site hernia and thromboembolicphenomena etc., have been previously well described. Bowel manipu-lation can be time-consuming during laparoscopy compared to openprocedure. Although potential complications specific to the ileal ma-nipulation under laparoscopy include ileus, bowel stricture, anastomo-sis stricture, etc., the laparoscopic approach may minimize some ofthese problems compared with open procedures. Additionally adher-ence to basic surgical principles during surgical reanastomosis shouldyield results comparable to the open anastomosis.

In conclusion, pure laparoscopic enterocystoplasty in children isan advanced procedure that is technically demanding. Although it ap-pears feasible and provides a minimally invasive option to bladder aug-mentation, its equivalency or superiority over laparoscopic assisted orconventional open techniques remains to be demonstrated.

References1. Lorenzo AJ, Cerveira J, Farhat WA. Pediatric laparoscopic ileal cystoplasty: completeintracorporeal surgical technique. Urology 69:977-81, 2007.2. Elliott SP, Meng MV, Anwar HP, et al. Complete laparoscopic ileal cystoplasty, Urology59: 939-43, 2002.3. Gundeti MS, Godbole PP, Wilcox DT. Is bowel preparation required before cystoplasty inchildren? J Urol 176:1574-7, 2006.

SAVE THE DATE

13



IntroductionAs with free-hand laparoscopy, robotic-assisted laparoscopy

(RALS) has been gradually incorporated over time as a tool for pediat-ric urologists. Numerous case reports have been published and afterthis initial enthusiasm, more mature and prospective studies are ap-pearing with increasingly thoughtful analysis. The most common ro-botic procedure in pediatric urology is pyeloplasty. Other proceduressuch as ureteral reimplantation, both intra- or extravesical, nephrec-tomy (including partial), ureteroureterostomy, pyeloureterostomy,pyelolithotomy, and appendicovesiscostomy have been described,among others. Our aim is to describe the principles of the basic tech-niques and highlight specific points and their outcomes.

Kidney SurgeryMost renal surgery beyond a simple nephrectomy appears to be

well-suited for robotic use in which the advantages of vision and deli-cate dexterity are of value, in contrast to conventional laparoscopy.Even simple nephrectomy is benefited with the robotic system to pro-vide careful access to and control of the hilum.

TechniqueProper trocar placement is critical for efficiency. Most renal pro-

cedures can be performed with a similar port placement and access.Port placement as evolved and improved over time. In children there isno specific distance needed between ports, providing that a symmetriclayout is afforded. If the area that we need to work in is small, we canplace the ports closer. For example, a pyeloplasty in an infant mayhave ports as close as 2 inches due to the small abdominal size, whilein a teen, the distance may be two times that. We have not been limitedsignificantly by age, and children as young as 3 months (about 7 kg)have undergone successful robotic pyeloplasty. The key element in portpositioning is symmetric alignment about the central camera axis, anda recognition of the working room requirements of the cannulae andinstruments. If the port entry is too close to the area of interest, move-ment is limited.

The 12 mm camera port is placed in the umbilicus followed by a 5or 8 mm working port midway between the umbilicus and the xyphoid.The patient is then rotated to raise the ipsilateral side and the dilatedrenal pelvis or kidney is identified. The position of the UPJ (forpyeloplasty) is used to determine the position of the inferior workingport so that it is symmetric with the upper working port with the cam-era oriented toward the area of surgery. With large renal pelves orsmaller children, the inferior port will need to be more inferior andmedial.

For pyeloplasty, the pelvis is exposed transmesenterically on theleft side when visible or after reflecting the colon. Often the ureter isfirst identified and guides the exposure of the pelvis. Subsequently,the ureter and renal pelvis are mobilized and a hitch stitch is placedthrough the abdominal wall and passed through the upper part of thepelvis and re-passed through the abdomen. It is then snapped at theappropriate degree of tension to maintain stability of the UPJ and lift itfrom the inevitable puddle of urine and blood. The pelvis is transected

The Role of Robotics in Pediatric UrologyCarlo Camargo Passerotti, M.D., Ph.D., Assistant Professor, Urologic Clinic, São Paulo University, São Paulo, Brazil

Craig Andrew Peters, M.D., John E. Cole Professor of Urology, Division of Pediatric Urology, University of Virginia, Charlottesville

and used as a handle for the ureter during spatulation and anastomosis,and eventually removed. The anastomosis is performed with absorb-able suture ranging from 7-0 to 5-0 depending on patient size. Ureteralstenting is advisable, either placed retrograde before the procedure (withor without an extraction string), or antegrade during the repair. A per-cutaneous nephroureteral stent can also be used but is more difficult toplace. A bladder catheter is left in place overnight.

OutcomesInitial results of pyeloplasty have been reported and appear to be

similar to open surgery with 95% success.1,3 No significant intra-op-erative complications have been reported in these three series.Reoperative cases have been undertaken successfully as well.4

Partial nephrectomy has been performed with a similar set-up asfor pyeloplasty, but the renal hilum must be fully exposed for adequatevascular control. We have chosen to use a fourth port to provide retrac-tion of the liver on right-sided procedures. The ability to close the re-nal defect with mattress sutures provides an advantage over conven-tional laparoscopic methods, and may limit the occurrence of urinoma.

Ureteral SurgeryFew reports have been published utilizing RALS to correct ure-

teral abnormalities. Ureteroureterostomies for calculi, ureteral folds,retro-caval ureters and other uncommon pathologies would all be readilyamenable to robotic procedures. In the setting of duplication anoma-lies, uretero-ureterostomy or ureteropyelostomy have been performedwith good success using a similar surgical plan as pyeloplasty. Evenwhen upper pole function is limited, a simple drainage procedure maybe more efficient than a partial nephrectomy. Outcomes have been goodand without complications.

Pelvic SurgeryIn infants, several procedures can be performed robotically in the

pelvis, particularly extravesical ureteroplasty for reflux, and includingintravesical ureteral reimplantation, urachal resection and Mulleriancyst excision.

Technique for Extravesical Ureteral ReimplantationThe most common anti-reflux procedure reported has been the

extra-vesical Lich-Gregoir. Similar port placements are used for otherpelvic procedures as this provides optimal exposure of the retrovesicalspace. The camera port is placed in the umbilicus and the two workingports are placed in the mid-clavicular lines at about the level of theumbilicus. This port placement is favorable for treating either one orboth ureters. The ureter can be seen just outside the bladder and theperitoneum lying on top is incised transversely behind the bladder. Theureter is dissected and traction is placed until the hiatus is exposed. Aholding suture facilitates bladder stabilization and exposure of the hia-tus. The bladder muscle is incised with cautery to create the detrusortunnel. While it would be ideal to spare any neural structures in thisarea to limit the risk of post-operative retention, the ability to recog-nize these structures remains uncertain in our experience. Care must

14


be taken to ensure the tunnel is of adequate length. Sometimes, themagnification provided by the robotic system may overestimate thetunnel length. This may be one cause for the persistence of reflux.Conversely, with the bladder only partially filled, the effective tunnellength may be more than is apparent. The muscle layer is closed overthe ureter with interrupted absorbable suture, from the proximal to dis-tal aspect.

OutcomesThere are few reports on extravesical ureteral reimplantation, but

excellent success has been noted without post-operative retention inbilateral cases. Our experience with bilateral extravesical reimplantationhas included occasional episodes of transient retention, but we havecontinued to employ the technique. The published suggestion thatVCUG is not needed, however, is premature in this emerging technol-ogy. No complications have been reported. Intravesical reimplants alsohave been reported with adequate outcomes.7 Whether these proce-dures afford a significant benefit over open or endoscopic surgery re-mains undefined as even open procedures are being performed on aday-surgery basis. It is uncertain if currently available outcomes pa-rameters are sensitive enough to detect any appreciable differences.Thefew reports on excision of Mullerian remnants and ureteroplasty haveshown good outcomes without complications.8

HorizonsMore complex reconstructive procedures are being explored ten-

tatively, and initial reports are encouraging. Continent diversion9, ilealaugmentation and bladder neck sling, as well as pyelolithotomy10 havebeen attempted. The future evolution of robotic surgery in pediatricurology is yet to be defined, but is likely to offer safe, efficient, mini-mally invasive surgical options for a wide variety of procedures. Thedetermination of benefits will require more robust outcome parametersthat reflect patient morbidity, both physiologically and perceptually.The valuation of those benefits, however, is not likely to be determined

by the pediatric urology community. With the inevitable innovationsin technology, the capabilities of robotic surgery will increase as costdecreases. It will be important that the pediatric urology communityparticipate actively in this evolution to ensure that it is applicable tochildren.

ConclusionsOverall, robotic-assisted laparoscopic procedures in pediatric urol-

ogy have been performed safely and effectively with a shorter learningcurve than conventional laparoscopy. Ongoing experience will improvesurgical techniques and the likely technological evolution will permiteven more utility.

References1. Atug F, Woods M, Burgess SV, Castle EP, Thomas R. Robotic assisted laparoscopicpyeloplasty in children. J Urol, 174: 1440-1442, 2005.2. Lee RS, Retik AB, Borer JG, Peters C A. Pediatric robot assisted laparoscopic dismemberedpyeloplasty: comparison with a cohort of open surgery. J Urol, 175: 683-687; discussion687, 2006.3. Yee DS, Shanberg AM, Duel BP, Rodriguez E, Eichel L, Rajpoot D. Initial comparison ofrobotic-assisted laparoscopic versus open pyeloplasty in children. Urology, 67: 599-602,2006.4. Passerotti CC, Nguyen HT, Eisner BH, Lee RS, Peters CA.Laparoscopic reoperativepediatric pyeloplasty with robotic assistance. J Endourol, 21: 1137-1140, 2007.5.Passerotti CC, Diamond DA, Borer JG, Eisner BH, Barrisford G, Nguyen HT.Robot-assistedlaparoscopic ureteroureterostomy: description of technique. J Endourol, 22: 581-584,discussion 585, 2008.6. Casale P, Patel RP, Kolon T F. Nerve sparing robotic extravesical ureteral reimplantation.J Urol, 179: 1987-1989; discussion 1990, 2008.7. Peters CA, Woo R. Intravesical robotically assisted bilateral ureteral reimplantation. JEndourol, 19: 618-621; discussion 621-612, 2005.8. Passerotti C, Cendron M, Gargollo P, Diamond DA, Borer J G, Cilento B, et al. Minimallyinvasive surgical approaches to retrovesical structures. Int J Med Robot, 3: 307-311, 2007.9. Pedraza R, Weiser A, Franco I. Laparoscopic appendicovesicostomy (Mitrofanoffprocedure) in a child using the da Vinci robotic system. J Urol, 171: 1652-1653, 2004.10. Lee RS, Passerotti CC, Cendron M, Estrada CR, Borer JG, Peters CA. Early results ofrobot assisted laparoscopic lithotomy in adolescents. J Urol, 177: 2306-2309; discussion2309-2310, 2007.

2009 - 2010 SPU Research GrantAwards Available

The Society for Pediatric Urology is pleased to announce its 2009 - 2010 Research Grant Awards. Research awardsof up to $30,000 will be presented to promising investigators who meet the appropriate criteria and whose projectsare selected by the Research Committee.

THE DEADLINE FOR APPLICATION IS FEBRUARY 20, 2009.

The Research Awards will be presented during the SPU Annual Meeting, April 25, 2009 at the Palmoer House HiltonHotel in Chicago, Illinois. Recipients are expected to be present at the Annual Meeting to be introduced to themembership and receive their award, as well as to present a five minute synopsis on their research. Successfulcandidates will be notified in advance of the Annual Meeting.

For additional information and to apply, please visit the SPU website: www.spuonline.org.

15


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Dialogues in Pediatric UrologyDialogues in Pediatric Urology

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Contributors

Alisa Berger, M.D. and

Fernando Ferrer, M.D.

Hartford Children’s HospitalMartin A. Koyle, M.D.

Denver Children’s HospitalMichael Ritchey, MD

University of Texas, HoustonJonathan Ross, M.D.

Cleveland ClinicRobert C. Shamberger, M.D.

Children’s Hospital, Boston

The management of childhood renal tumors continues to evolve. A panel of experts pre-sented an update on selected areas of this broad topic at the American Academy of Pediatrics inSan Francisco in October, 2004. Dr. Mike Ritchey (MR), Professor and Chair of Urology at theUniversity of Texas in Houston presented the current proposals for management of bilateral Wilms’tumor. Dr. Robert Shamberger (RS), Professor and Chief of Pediatric Surgery at Harvard andBoston Children’s Hospital spoke on the data regarding surgery alone as treatment for the smallstage 1 Wilms’ tumor in infants. Both Dr. Ritchey and Dr. Shamberger are uniquely qualified tospeak on these topics from their positions as surgical representatives to the renal committee of theChildren’s Oncology Group (COG), previously the National Wilms’ Tumor Committee. Dr.Jonathan Ross (JR), Professor and Chief of Pediatric Urology at the Cleveland Clinic, pinch-hitting for Dr. Fernando Ferrer, Chief of Pediatric Urology at the University of Connecticut,presented the current status of management of renal cell carcinoma and Dr. Marty Koyle (MK),Professor and Chief of Pediatric Urology at the University of Colorado and Denver Children’sHospital, then presented several cases to the panel eliciting discussion about nephroblastomatosis,the incidental renal mass and the “inoperable” Wilms’ tumor. The session was moderated bymyself (BB).

Our current management of Wilms’ tumor continues to evolve at a rapid pace. If one were tohave this read monograph 10 years ago, thoughts of disbelief and even negligence might havecrossed one’s mind. But here we are continuing to challenge our traditional management proto-cols in a truly scientific way that could be done only with the organized control trials that we haveall come to know through NWTSG, SIOP, and COG. It is a clear testimony to the ultimate inscientific clinical trials and the search for evidence based medicine.

This panel explores the latest evidence in the management of bilateral Wilms’ tumor, theoption for no adjuvant therapy following nephrectomy for low risk Wilms’ tumor, and the differ-entiation of renal cell carcinoma in children compared with adults. I applaud Bruce Broecker andhis team of experts for putting together a classic issue on renal tumors in children.

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