• How We Perform Our Surgery
• Potential Complications
• Final Thoughts

Major advances in laparoscopic surgery have allowed for less invasive surgery in the realm of urology with the benefits of decreased post-operative discomfort and healing time as well as improved cosmetic results. Initially, laparoscopy had limited diagnostic and therapeutic uses. With the advent of automatic clip appliers, stapling devices, impermeable organ removal bags, and morcellating devices, the scope of procedures that can be performed laparoscopically has been broadened substantially. In urology, such advances have allowed for laparoscopic varicocelectomies, bladder augmentations, urinary diversions, ureterolysis, adrenalectomies, nephrectomies, and nephro-ureterectomies. We now have performed over 50 laparoscopic nephrectomies on children at our center. Our director Dr. Dix Poppas has performed all the operations.

Some of the indications for nephrectomy have included large painful, multicystic dysplastic kidneys, poorly controlled renovascular hypertension, and a non-functioning kidney secondary to severe vesicoureteral reflux. Other children treated with this procedure have presented with urinary tract infections in the setting of non-functioning kidneys secondary to congenital UPJ obstructions. In one of these children (a 1 year old girl), a horseshoe kidney was discovered with a non-functioning right kidney secondary to UPJ obstruction.

We have also performed laparoscopic nephro-ureterectomies on children. In this case, we remove the kidney and the entire ureter. The ureter is the muscular tube that drains urine into the bladder from the kidney. Several of these children presented with non-functioning kidneys secondary to severe vesicoureteral reflux. Reflux is a condition, which is described elsewhere in our web site. In short, reflux allows the passage of infected urine into the kidney through the ureter. This can result in chronic infection and scarring of the kidney leading to unilateral and sometimes bilateral infections. The burned-out scarred kidneys that continue to have infections must be removed.

We have also performed partial nephrectomies with ureterectomy on several children. These patients presented with urinary tract infections and were found to have duplicated collecting systems. In this situation we were able to separate the nonfunctioning portion of the duplicated kidney from the normally functioning portion in order to preserve future kidney function.

How do we perform our surgery?
All of our patients are administered general endotracheal anesthesia. This means the child is completely asleep with anesthesia. The endotracheal tube protects the airway and allows for us to breathe for the patient. We perform formal cystoscopy at the start of our procedures. Here we use a camera to look inside the bladder and pass a stent with an infrared laser fiber (Infravision infrared ureteral stent, Gabriel Medical, Inc., Lafayette, LA) for assistance in identification and dissection of the ureter if need be. Three small skin incisions are made in order to place the laparoscopic camera and surgical instruments. The incisions are 1.5 cm in size usually; small enough to be dressed with a Band-Aid at the end of the case.

The first incision is made in the upper portion of the umbilicus. Carbon Dioxide gas is used to insufflate the belly allowing us to have room to visualize and perform the procedure. The other two incisions are made just below the rib overlying the affected kidney, and over the region of the hipbone. Now with all of the instruments in place, the kidney and ureter can be freed from surrounding tissues and all portions of the kidney that need to be removed can be done laparoscopically. At the end of the procedure, the abdominal cavity is inspected for any sites of bleeding. Once all is bleeding is stopped, the skin incisions are covered with Band-Aids or appropriate sterile dressings.

The patient is immediately transported to the recovery room after being wakened up in the operating room. Most of the children are eating a regular meal the same day and can go home that day. Some of the older children spend an extra day in the hospital until they are tolerating a regular meal.

Potential Complications:
Potential complications include infection, bleeding, and anesthesia related complications. At our center, not a single case has been converted to an open procedure. We were able to perform all of the cases laparoscopically as we intended to. Additionally, not a single child has been transfused. Our blood loss averages less than 5 cc (a tablespoon). Anesthesia related concerns are always present surrounding any operation. We are blessed with a talented staff of pediatric anesthesiologists who only administer anesthesia to children and are specialty trained in pediatric anesthesia. With their help, we are able to report a 0% rate of anesthesia related complications during our laparoscopic cases.

Final thoughts:
Laparoscopy and minimally invasive surgery is gaining popularity for a number of different procedures in pediatric urology with the primary universal advantages of reduced patient post-operative discomfort, decreased duration of hospital stays, and improved cosmetic results. As procedures have been performed successfully on adults, their application to the pediatric population has been investigated with good results, even in very young patients.

Minimally invasive surgery and laparoscopy have rapidly come to the forefront as a feasible option for children with certain urological diseases. The advantages of decreased post-operative pain short hospital stays (with the possibility of performing such procedures on an outpatient basis in select patients), and improved cosmetic results are evident.