Laparoscopic partial nephrectomy in duplex kidneys in infants and children: results of an European multicentric survey

Laparoscopic Partial Nephrectomy for Duplex Kidneys in Infants and Children: How We Do It

Duplication anomalies of the kidney represent common congenital malformations of the urinary tract. A duplex kidney has often one pole that is poorly or nonfunctioning. In this last case, surgery may be indicated to remove the nonfunctioning pole. The most common indications for partial nephrectomy in pediatrics include symptomatic vesicoureteral reflux to the nonfunctioning pole and/or ectopic ureter or ureterocele causing urinary incontinence. In this article, we describe the technique of laparoscopic partial nephrectomy in infants and children with duplex kidney. A surgical procedure properly executed following critical technical steps is the key factor for the success of surgery.

Technical standardization of ICG near-infrared fluorescence (NIRF) laparoscopic partial nephrectomy for duplex kidney in pediatric patients

Purpose

This study aimed to standardize the operative technique of indocyanine green (ICG) near-infrared fluorescence (NIRF) laparoscopic partial nephrectomy (LPN) and compare it with the standard technique.

Methods

In the last 4 years, we performed 22 LPN (14 right-sided, 8 left-sided) in children with non-functioning moiety of duplex kidney. Patients included 12 girls and 10 boys with a median age of 3.9 years (range 1–10). Patients were grouped according to the use of ICG-NIRF: G1 included 12 patients operated using ICG-NIRF and G2 included 10 patients receiving the standard technique. We standardized the technique of injection of ICG in three different steps.

Results

The median operative time was significantly lower in G1 [87 min (range 68–110)] compared with G2 [140 min (range 70–220)] (p = 0.001). One intra-operative complication occurred in G2. At post-operative ultrasound (US), the residual moiety was normal in all patients. An asymptomatic renal cyst related to the site of surgery was visualized at US in 8/22 (36%), with a significantly higher incidence in G2 (6/10, 60%) compared with G1 (2/12, 16.6%) (p = 0.001). Renogram demonstrated no loss of function of residual moiety. No allergic reactions to ICG occurred.

Conclusion

ICG-NIRF LPN is technically easier, quicker, and safer compared with the standard technique. The main advantages of using ICG-NIRF during LPN are the clear identification of normal ureter, vasculature of non-functioning pole, and demarcation line between the avascular and the perfused pole. The main limitation of ICG technology remains the need for specific laparoscopic equipment that is not always available.

Laparoscopic Upper-pole Heminephrectomy for the Management of Duplex Kidney: Outcomes of a Multicenter Cohort

OBJECTIVE

To analyze the outcomes of patients undergoing upper-pole heminephrectomy surgery and to assess the different variables that may have an impact on outcome, specifically regarding morbidity and the need for further surgeries.

MATERIALS AND METHODS

A retrospective study of patients who underwent laparoscopic upper-pole heminephrectomy for a nonfunctional moiety between August 2007 and December 2019 was conducted at 3 centers. A total of 130 patients met the inclusion criteria. A transperitoneal approach was used. The following variables were evaluated: (1) preoperative: presentation, presence of ureterocele and history of ureterocele incision, hydronephrosis grade, presence of vesicoureteral reflux (VUR), and differential renal function (DRF) on renal scintigraphy; and (2) postoperative outcomes: Doppler ultrasound, renal scintigraphy, complications, febrile urinary tract infection, lower urinary tract symptoms, and need for further surgery. Findings were considered statistically significant at P <.05.

RESULTS

Postoperative complications were observed in 5 patients (3.8%). Six patients (4.6%) needed further surgeries after heminephrectomy. The presence of ureterocele and VUR was related with the need for further surgeries odds ratio (OR) 4.91, P = .0415) and the occurrence of postoperative febrile urinary tract infection (OR 2.81, P = .0376). A 13.9% incidence of lower urinary tract symptoms was found with no difference between patients with ureterocele and those with an ectopic ureter. Renal scintigraphy showed a median decrease in DRF of 2.7%. No patient had complete loss of function.

CONCLUSION

Laparoscopic upper-pole heminephrectomy showed to be a feasible and safe procedure. In most patients this surgery will be the definitive procedure. Patients with both VUR and ureterocele will need special consideration. No significant loss of function in the remaining lower moiety was found.

Near-Infrared fluorescence imaging using indocyanine green (ICG): Emerging applications in pediatric urology

BACKGROUND

Near-infrared fluorescence (NIRF) imaging with indocyanine green (ICG) has been recently adopted in pediatric minimally invasive surgery (MIS) in order to improve intra-operative visualization of anatomic structures and facilitate surgery.

OBJECTIVE

This study aimed to report our preliminary experience using ICG technology in pediatric urology using laparoscopy and robotics.

STUDY DESIGN

ICG technology was adopted in 57 laparoscopic or robotic urological procedures performed in our unit over a 24-month period: 41 (38 laparoscopic - 3 robotic) left varicocele repairs with intra-operative lymphography and 16 renal procedures (12 laparoscopic - 4 robotic) including 9 partial nephrectomies, 3 nephrectomies and 4 renal cyst deroofings.

RESULTS

The ICG solution was injected intravenously in renal procedures or into the testis body in case of varicocele repair. Regarding the timing of the administration, the ICG injection was performed intra-operatively in all cases and allowed the visualization of the anatomic structures in a matter of 30-60 s. The dosage of ICG was 0.3 mg/mL/kg in all indications. All procedures were completed laparoscopically or robotically without conversions. No adverse and allergic reactions to ICG and other complications occurred postoperatively.

DISCUSSION

This paper describes for the first time in pediatric urology that ICG-guided NIRF imaging may be helpful in laparoscopic and robotic procedures. In case of varicocele repair, ICG-enhanced fluorescence allowed to perform a lymphatic-sparing procedure and avoid the risk of postoperative hydrocele. In case of partial nephrectomy, ICG-guided NIRF was helpful to visualize the vascularization of the non-functioning moiety, identify the dissection plane between the two moieties (Fig. 1) and check the perfusion of the residual parenchyma after resection of the non-functioning pole. In case of renal cyst deroofing, ICG-guided NIRF aided to identify the avascular cyst dome and to guide its resection. No real benefits of using ICG-enhanced fluorescence were observed during nephrectomy.

CONCLUSION

Our preliminary experience confirmed the safety and efficacy of ICG technology in pediatric urology and highlighted its potential advantages as adjunctive surgical technology in patients undergoing laparoscopic or robotic urological procedures. Use of NIRF was also cost-effective as no added costs were required except for the ICG dye (cost 40 eur per bottle). The most common and useful applications in pediatric urology included varicocele repair, partial nephrectomy ad renal cyst deroofing. The main limitation is the specific equipment needed in laparoscopy, that is not available in all centers whereas the robot is equipped with the Firefly® software for NIRF.

Dorsal lumbotomy for pediatric upper pole hemi-nephrectomy: Back (door) to the future?

INTRODUCTION

Upper pole heminephrectomy (UHN) is performed for two main indications in children: ectopic ureterocele and duplication anomalies with upper pole ectopy, both in the context of a poorly functioning upper pole moiety. Current popular techniques for conducting UHN include laparoscopic (LPN) and robot-assisted laparoscopic (RAPN).

OBJECTIVE

To evaluate outcomes following dorsal lumbotomy (DL), an open approach used historically for pyeloplasty and pyelolithotomy, and in which no clinical trials or exclusive case-series have been conducted for upper pole hemi-nephrectomy (UHN) in children. We ultimately aim to compare our outcomes following DL at our centre to that of published outcomes of minimally invasive approaches to UHN.

STUDY DESIGN

Institutional board review was obtained (H18-03716) for a retrospective review of 50 UHN performed in 49 consecutive pediatric patients using the DL approach by a single surgeon between 2001 and 2019. Clinical variables and indicators included age, sex, weight, skin-to-skin time, total operating room time, duration of hospital stay, post-operative complications, analgesic requirements, and post-operative ultrasound results.

RESULTS

Of 50 UHN performed, 23 had a presurgical diagnosis of ectopic ureter, and 27 ureterocele. Mean weight of patients was 12.61 kg, and the mean age at surgery was 24.55 months. Mean (range) for time between skin incision and closure was 88.5 (62-132) minutes, and the mean (range) total operating room time was 138.5 (70-180) minutes. There were neither intraoperative complications nor transfusions. The mean (range) post-operative opioid delivered was 0.73 (0.00-2.00) mg/kg/day. Mean (range) post-operative ibuprofen delivered was 5.41 (0.00-37.73) mg/kg/day. Median length of hospital stay was 2 days. No patient received post-operative prescriptions for narcotics at discharge. There were no wound complications. One patient had secondary atrophy of the lower pole. Secondary lower tract surgery, unrelated to surgical approach, was performed in five patients. Ten patients experienced a urinary tract infection at some point after surgery.

CONCLUSION

DL is safe, feasible, and produces operative outcomes and times comparable to that of laparoscopic and robotic techniques. These findings as well as operative costs should be considered when selecting a surgical technique for UHN.

Application of the Clavien-Dindo classification to a pediatric surgical network

INTRODUCTION

A comprehensive validated system to evaluate surgical complications is required in our specialty to facilitate comparison and audit. The Clavien-Dindo (CD) classification of post-surgical complications was originally described in an adult general surgical setting in 1992 and has become widely used. We aimed to apply this to a pediatric surgical setting.

METHODS

Data were collected on emergency and elective surgical activity together with complications in a prospective audit over a recent 4-month period in three geographical conjoined regional pediatric surgical units (including two major trauma centres). Briefly the CD classification codes complications according to degree of harm and magnitude of intervention required [I - V (death) with III and IV sub-divided according to whether general anesthesia was needed]. Length of stay and mode of admission were recorded. Data are given as median (range). Non-parametric comparison was used, and a p value of <0.05 was regarded as significant.

RESULTS

During the period JULY - OCT 2018 (inclusive), there were 1822 admissions (elective, n = 1186: emergency, n = 636) and 1556 operations (elective, n = 1189, and of these 393 were urological). There were 69 patient complications: CDI (n = 7), CD-II (n = 19), CD-IIIa (n = 4), CD-IIIb (n = 28), CD-IV (n = 4), CD-V (n = 7). Deaths were principally in neonates and due to NEC (n = 6) at 2.5 (1-140) days post-operatively. There was a single post-traumatic death in an adolescent. LOS was 9 (0-217) days in CD I-IV. The incidence of any complication was 4.4%, of serious complication (defined as ≥CD III) 2.6% (A = 2.1%, B = 2.0%, and C = 3.2%: p = 0.16), and of death 0.45%. The most frequent complications were wound infection (n = 12) and post-appendicectomy collections/abscess (n = 10).

CONCLUSIONS

This appears to be the 1st report of the C-D classification in a general pediatric surgery network and can be considered a benchmark. The risk of death or serious harm is very low in such a practice.

TYPE OF STUDY

Prospective Cohort Study.

LEVEL OF EVIDENCE

IIb.

Laparoscopic Heminephrectomy for Duplex Kidney in Children-The Learning Curve

Objectives: Outcomes evolution during the learning curve of laparoscopic transperitoneal heminephrectomy in children with a duplex kidney. Materials and Methods: The data of 33 children, operated on between 2008 and 2017, with complicated duplex kidney, were subjected to a retrospective analysis. All patients were operated on by transperitoneal access using the laparoscopic technique. Patients were divided into two groups (1: subsequent operation 1-16, and 2: operations 17-33) to evaluate the learning curve. Results: There was no need for conversion. Total complications occurred in seven patients in Group 1 and 2 patients of Group 2 (p < 0.05). Two patients (6%) (both upper pole heminephrectomies) required reoperation to remove the ureter stump because of recurrent UTIs due to undiagnosed VUR to the stump (1 from each of Groups 1 and 2). Prolonged urine leakage (over 4 days) was observed in four patients (12%; all from group 1); in three patients, conservative treatment was successful, while the placement of a DJ catheter was needed in the fourth. A significant decrease of kidney function (>6%) in scintigraphy was observed in two of the 15 patients after the surgery. The time of surgery decreased from 140 (range 85-185) min in Group 1 to 125 (range 100-150) min in Group 2 (p < 0.05). Conclusions: Laparoscopic heminephrectomy is connected to the learning curve. Most complications occurred in the first 16 operations. With increasing experience, the time of operation decreased. In patients with reflux to the upper pole, referred for upper pole heminephrectomy, it is necessary to consider the removal of the ureter to the level of the vesicoureteral junction.

Transperitoneal laparoscopic heminephroureterectomy in pediatric population: A single-centre experience using a sealing device

INTRODUCTION

We sought to report the outcomes of transperitoneal laparoscopic heminephroureterectomy (LHNU) in pediatric population and to describe the technical details of this minimally invasive surgery.

METHODS

Seventeen pediatric patients (18 renal units), who had consecutive transperitoneal LHNU in our department between January 2012 and July 2017 were included in the study. In all patients, diagnostic cystoscopy and retrograde pyelography were carried out immediately before the operation. A catheter was inserted in the unaffected ureter and fixed. LHNU with a transperitoneal approach was carried out in all patients with the aid of LigaSure^®. After removal of the specimen, the intervention was finalized with the insertion of a drain. All intraoperative and postoperative data of the patients were recorded prospectively.

RESULTS

The average age of the patients was 55.9±35.8 months (range 8-121). The average duration of the operations was 121.7±24.0 minutes (range 100-200). The average hospitalization time was 1.6±0.4 days (range 1-2). No intraoperative complication occurred in our patients. The average followup period was 29.1±13.4 months (range 4-48). During the followup period, no complications were observed except one patient who had pyelonephritis within the first month of surgery.

CONCLUSIONS

Transperitoneal LHNU is a minimally invasive method that can be used safely in pediatric patients. Using a standardized technique during the procedure is critical to increase the success and decrease the complication rates.

What's the best minimal invasive approach to pediatric nephrectomy and heminephrectomy: conventional laparoscopy (CL), single-site (LESS) or robotics (RAS)?

BACKGROUND

Conventional laparoscopy (CL) using 3-5 mm ports has become the goldstandard for pediatric nephrectomy (N), heminephrectomy (HN) and heminephrecto-ureterectomy (HNU) for many years now. Recently the spectrum of minimal invasive surgery (MIS) has been extended by variants like laparoendoscopic single-site surgery (LESS) or robot-assisted surgery (RAS). However such technical developments tend to drive surgical euphoria and feasibility studies, but may miss adequate academic research about function and proven patients' benefits. This article delivers a comprehensive analysis of present pediatric studies comparing at least two MIS approaches to N, HN and HNU.

METHODS

A systematic literature-based search for studies published between 2011-2016 about CL versus LESS or RAS for pediatric N, HN, and HNU was performed using multiple electronic databases and sources. The level of evidence was determined using the Oxford Centre for Evidence-based Medicine (OCEBM) criteria. Single arm observational studies about N, HN or HNU using CL, LESS or RAS as well as publications including adult patients were excluded.

RESULTS

A total of 11 studies met defined inclusion criteria, reporting on CL versus LESS or RAS. No studies of OCEBM Level 1 or 2 were identified. Performing CL for N and HN limited evidence indicated reduced analgesic requirements and shorter hospital stay over open surgery, but longer operating time. Preservation of renal function of the remaining moiety after CL-HN was 95%. Importantly, of patients losing their remaining moiety, median age at surgery was 9 months (range, 4-42 months), and all except 1 (6/7) had an upper pole HN. Several authors compared TNP versus RPN access for CL and confirmed a longer operating time for RPN versus TPN-NU. Moreover one study reported a longer ureteric stump in RPN versus TPN-HNU (range, 2-5 cm vs. 3-7 mm). Disadvantages of LESS or RAS over CL were longer operative time and higher total costs (RAS). There were no differences regarding complications, success rates, or short-term outcomes between pediatric RAS versus CL. No long-term studies about preservation of renal function or length of ureteric stump using LESS or RAS could be retrieved.

CONCLUSIONS

Several approaches to MIS-NU and HNU are available today. CL represents the method of choice for any age group. TPN or RPN can be chosen according to age of the patient. LESS and RAS offer distinct advantages, but also lack evident patients' benefits over CL at present. Hopefully, as pediatric MIS advances over the next decade, larger studies comparing CL, LESS or RAS directly for pediatric NU and HNU will be published to gain a higher level of evidence what's really best for the child.

Prospective assessment of complications on a daily basis is essential to determine morbidity and mortality in routine pediatric surgery

AIMS OF THE STUDY

We aimed to assess postoperative complications prospectively on a daily basis and hypothesized that this would lead to an increase in the number of detected complications.

METHODS

Surgical complications were assessed prospectively during a period of 8months. Systematic documentation was carried out daily during a team meeting (period S). Data were compared to those of a preceding period of 8-months of nonsystematic assessment (period N) in which complications had been documented in a self-reporting fashion. Complications were classified according to the Clavien-Dindo classification.

RESULTS

A total of 1291 patients (mean age: 6.6years) were included. During period S complications were determined in 16% of 790 operations compared to 4% of 741 procedures in period N (p<0.01). This difference was owing to an increased detection of minor complications (grade I-III), i.e. wound infection, dysuria after hypospadias repair or postoperative bleeding. In contrast, the incidence of severe complications (grade IV+V) was not significantly different between the time periods (1.3% in period S and 0.8% in period N). Most frequent major complications were cardiopulmonary arrest, enterocolitis, and death. Severe complications accounted for 8% of complications discussed during weekly morbidity and mortality conferences in period S versus 22% in period N (p<0.05).

CONCLUSION

Our results indicate that a systematic documentation of complications on a daily basis reveals a more realistic picture of the incidence of pediatric surgical complications and should be the method of choice.