LAPAROSCOPIC RETROPERITONEAL NEPHRECTOMY IN HIGH RISK CHILDREN

Factors affecting recovery of postoperative bowel function after pediatric laparoscopic surgery

BACKGROUND AND AIMS

Laparoscopic pediatric surgery allows a rapid postoperative rehabilitation and hospital discharge. However, the optimal postoperative pain management preserving advantages of this surgical technique remains to be determined. This study aimed to identify factors affecting the postoperative recovery of bowel function after laparoscopic surgery in children.

MATERIAL AND METHODS

A retrospective analysis of factors affecting recovery of bowel function in children and infants undergoing laparoscopic surgery between January 1, 2009 and September 30, 2009, was performed. Factors included were: Age, weight, extent of surgery (extensive, regional or local), chronic pain (sickle cell disease or chronic intestinal inflammatory disease), American Society of Anaesthesiologists status, postoperative analgesia (ketamine, morphine, nalbuphine, paracetamol, nonsteroidal anti-inflammatory drugs [NSAIDs], nefopam, regional analgesia) both in the Postanesthesia Care Unit and in the surgical ward; and surgical complications. Data analysis used classification and regression tree analysis (CART) with a 10-fold cross validation.

RESULTS

One hundred and sixty six patients were included in the analysis. Recovery of bowel function depended upon: The extent of surgery, the occurrence of postoperative surgical complications, the administration of postoperative morphine in the surgical ward, the coadministration of paracetamol and NSAIDs and/or nefopam in the surgical ward and the emergency character of the surgery. The CART method generated a decision tree with eight terminal nodes. The percentage of explained variability of the model and the cross validation were 58% and 49%, respectively.

CONCLUSION

Multimodal analgesia using nonopioid analgesia that allows decreasing postoperative morphine consumption should be considered for the speed of bowel function recovery after laparoscopic pediatric surgery.

Is retroperitoneoscopy the gold standard for endoscopic nephrectomy in children on peritoneal dialysis?

PURPOSE

The literature on minimally invasive nephrectomy in adults and children on peritoneal dialysis is sparse. Case reports suggest that the transperitoneal approach is effective. We present our experience with retroperitoneoscopic nephrectomy in children on peritoneal dialysis.

MATERIALS AND METHODS

At 11 consecutive retroperitoneoscopic nephrectomies a total of 14 kidneys were removed from 10 children with a mean age of 12 years. We used a 3-port lateral retroperitoneoscopic nephrectomy technique with active trainee participation. Preoperative and postoperative biochemistry results within 3 months of surgery were compared with the Wilcoxon signed rank test.

RESULTS

Three bilateral synchronous, 1 bilateral staged and 6 unilateral retroperitoneoscopic nephrectomies were done. Mean operative time was 174 minutes for unilateral and 458 minutes for bilateral nephrectomy, including 1 simultaneous peritoneal dialysis insertion and 1 umbilical hernia repair. No open conversion, blood transfusion or postoperative surgical complication was noted. Peritoneal dialysis was initiated at a median of 9 hours postoperatively and dialysate volume was titrated to target within a median of 60 hours. One patient with a small peritoneotomy needed temporary hemodialysis despite intraoperative airtight repair. After surgery median serum albumin increased from 30.0 to 34.3 gm/l.

CONCLUSIONS

Retroperitoneoscopic nephrectomy for end stage renal disease is a safe, effective technique that preserves peritoneal integrity in children who require immediate postoperative peritoneal dialysis. Avoiding post-nephrectomy hemodialysis decreases patient morbidity, preserving vessels for future vascular access. Compared to the literature on laparoscopy in this setting, retroperitoneoscopic nephrectomy can be considered the ideal approach for minimally invasive nephrectomy in patients on peritoneal dialysis.

Evolution of laparoscopy in pediatric urology

The use of laparoscopy has evolved over the last 30 years, particularly in the last decade, from merely extirpative or diagnostic procedures to intricate reconstructive procedures on the major genitourinary organs. The development of laparoscopy as a method of treating urological problems has progressed more slowly in children compared with adults; perhaps due to the availability of miniaturized technology, the steep learning curve and the high success of traditional open surgery. This article seeks to provide a comprehensive review of the evolution of laparoscopy from its inception to its present-day applications in the field of pediatric urology, including the current indications and results of various laparoscopic procedures.

[Complications in laparoscopy renal surgery in pediatric age: analysis of our experience and literature review]

INTRODUCTION

The development of the minimally invasive surgery in pediatric age has been slower than in the adult age since their advantages are not so clear. The learning curve and the complications presented during this period, as well as the type of material used has been the factors that have contributed to this fact.

OBJECTIVE

We collected our experience and the complications presented in renal laparoscopic exegesis surgery, adding a review of the published literature to date.

MATERIALS AND METHODS

Retrospective study of our clinical cases in that we practiced laparoscopic renal exegesis surgery. We collected 56 cases from January 2003, when it was implanted, to September 2008. We had 36 boys (64%) and 20 girls (36%). The mean age was 3.6 years. We analyzed principal diagnosis, the situation that conducted to the surgery and the type of surgery performed, time of surgery, hospital stay and complications with their solution. The results were analyzed the statistical program SPSS (SPSSCorp, Chicago, Illinois). The literature review was practiced in MEDLINE, EMBASE and COCHRANE database. The selected works were reviewed by two investigators. Series containing adults were excluded.

RESULTS

We perfomed 42 nephrectomies (75%), 13 heminephrectomies (23%) and 1 quistectomy (2%). 5 cases (9%) were done by retroperitoneoscopy and 51 cases (91%) transperitoneally. The mean operative time was 118 +/- 0,75 min, for nephrectomies; 192 +/- 1.07 min, for partial nephrectomies, 111 +/- 0,64 for nephroureterectomies and 240 min for quistectomia. The mean hospital stay was 3.18 min (2-6) days for nephrectomies; 5.91 (3-11) days for partial nephrectomies, 3 days (2-4) for nephroureterectomies and 6 days for the quistectomy. We had 8 complications (14%): 2 conversions for bledding and technical difficulty and 6 postoperative complications (3 were minor complications, postoperative fever and 3 mayor (2 Urinomas and one pseudoaneurism, requiring 2 interventions and one catheter double J placement). The evolution has been satisfactory in all cases. In the bibliographic review 47 articles with a level of evidence IIIB were selected (Oxford Centers for Evidence-based Medicine). The main reasons to conversion to open surgery were vascular problems and the complication rate change from anyone to 37%.

CONCLUSIONS

Laparoscopic surgery has proved to be a secure and feasible technique in the treatment of benign renal pathology in pediatric age with satisfactory results. Actually the indications are expanding to reconstructive procedures, with promising results, and selected oncologic procedures.

Laparoscopy in paediatric urology: present status

The spectrum of laparoscopic surgery in children has developed dramatically; what was initially used as a diagnostic method to identify an impalpable testis is now commonly used for complex reconstructive procedures such as pyeloplasty. Laparoscopic orchidopexy and nephrectomy are well established and are used at many centres. Laparoscopic partial nephrectomy, adrenalectomy and dismembered pyeloplasty series have reported shorter hospital stays and operative times that are comparable with that of open techniques, and/or decreasing with experience. The initial experiences with laparoscopic ureteric re-implantation and laparoscopically assisted bladder reconstructive surgery are reported, with encouraging results for feasibility, hospital stay, and cosmetic outcome.

Minimally invasive surgery for urologic disease in children

This article is a comprehensive review of the current indications and recent literature pertaining to laparoscopic techniques in pediatric urology. Basic concepts such as instrumentation, anesthetic considerations, and complications are reviewed. Specific techniques and indications are also explored. As the field of pediatric urology continues to expand, it still lags behind adult urology. With improvements in technology, however, and with new surgeons entering the field with a basic laparoscopic background, pediatric urologic laparoscopy continues to progress. Currently, procedures such as laparoscopic exploration for undescended testicles and laparoscopic nephrectomy are accepted as the 'gold standard', and are performed at most institutions. Other procedures, such as laparoscopic pyeloplasty and laparoscopic reconstructive surgery, have only recently been introduced and are primarily available at centers with surgeons experienced in laparoscopy. It is our hope that minimally invasive surgical approaches to urologic conditions will become available to all children and become commonplace at most institutions.

[The position of laparoscopic surgery in pediatric urology]

With growing experience in laparoscopic techniques there is a switch in pediatrics from ablative surgery to reconstructive procedures. Besides the established procedures such as laparoscopic nephrectomy and orchidopexy, procedures like heminephrectomy and pyeloplasty have proven practicable and become standard therapies in children and infants. Due to technical advances, as shown for our own patients, the number of treated infants is still increasing. However, laparoscopic reconstructive procedures presuppose a good deal of experience in preparation and suture techniques, and remain reserved for centers with daily experience in laparoscopy. Daily experience with difficult urological laparoscopic procedures in adults will remain more common than in pediatric centres.

Retroperitoneal laparoscopic nephrectomy in children: at last the gold standard?

PURPOSE

We analyzed our experience with retroperitoneal laparoscopic nephrectomy giving special attention to the learning curve, morbidity, and feasibility in a teaching institution.

MATERIAL AND METHODS

Between 1996 and 2004, we performed 104 laparoscopic nephrectomies in 88 children. Only four were performed via the transperitoneal approach, the others being via the retroperitoneal approach; the files of the latter were analyzed. Mean age was 5 years (20 days-15 years). Main indications were pretransplant nephrectomy for arterial hypertension, nephrotic syndrome or uremic hemolytic syndrome (51%), non-functioning kidney secondary to obstruction, reflux or ectopic ureter (38%), and multicystic dysplastic kidney (11%). Bilateral nephrectomy was performed in 13 children.

RESULTS

The lateral retroperitoneal approach was feasible in all cases even for those who had previous renal surgery. Conversion was not needed in any patient. No significant blood loss was observed. Mean operative time was 97 min (range 44-240) for unilateral nephrectomy; 46 nephrectomies were done in less than 90 min. In bilateral cases the mean operative time was 260 min (range 160-390). The operative time was less than 4 h in seven bilateral cases. Postoperative course was uneventful. Hospital stay was 1.9 days (range 1-3) for urological indications and 5 days (range 3-7) for patients with terminal renal disease. The procedure was initially performed by one surgeon, but was then expanded to other surgeons of the team, and safely taught to residents and fellows.

CONCLUSIONS

The procedure is safe, the learning curve is reasonable, teaching is feasible, operating time becomes with experience closer to open surgery without morbidity, and cosmetic results are excellent. This procedure may be considered as the gold standard for nephrectomy in children.

Hemodynamic and Respiratory Effects of Pediatric Urological Retroperitoneal Laparoscopic Surgery: A Prospective Study

PURPOSE

Our understanding of the effects of retroperitoneal CO(2) insufflation on cardiopulmonary variables in children remains limited. This study was designed to investigate prospectively the effect of CO(2) insufflation in a pediatric population undergoing retroperitoneal laparoscopic surgery.

MATERIALS AND METHODS

We prospectively evaluated a consecutive series of patients enrolled between July 2003 and August 2004. Anesthesia was administered following a standardized protocol. Data collection included respiratory rate, PAP, O(2) saturation, ETCO(2), HR, MAP, electrocardiogram and insufflation pressure. All variables were recorded before, during and after CO(2) insufflation at regular intervals of 1 to 2 minutes, with up to 23 measurements recorded for each period.

RESULTS

A total of 18 participants were recruited. Mean +/- SD for age and weight were 79.4 +/- 53.2 months and 26.7 +/- 15.5 kg, respectively. Mean retroperitoneal CO(2) insufflation pressure was kept at 12 mm Hg. Significant differences (p <0.05) in average ETCO(2), PAP and MAP were noted after CO(2) insufflation compared to baseline (pre-pneumoretroperitoneum) values. HR and temperature did not change. At completion of the laparoscopic intervention physiological variables exhibited a trend to return to baseline values.

CONCLUSIONS

This prospective study documents significant changes in systemic hemodynamic variables that seem to be directly associated with the insufflation of CO(2) during pediatric retroperitoneal laparoscopic surgery. This ongoing evaluation confirms the effect of laparoscopic urological surgery and CO(2) insufflation on cardiopulmonary function in children.

RETROPERITONEAL LAPAROSCOPIC VERSUS OPEN PYELOPLASTY IN CHILDREN

PURPOSE

The indications for laparoscopy in pediatric urology are expanding and yet the advantages over open surgery remain unclear. We compared the results of retroperitoneal laparoscopic vs open pyeloplasty for pyeloureteral junction obstruction in children.

MATERIALS AND METHODS

A total of 22 children with a mean age of 88 months (range 25 to 192) underwent laparoscopic dismembered pyeloplasty via the retroperitoneal approach. An additional 17 children with a mean age of 103 months (range 37 to 206) underwent similar procedures via open surgery through a flank incision. We retrospectively analyzed and compared operative time, the use of analgesics (acetaminophen or morphine derivatives) and hospital stay.

RESULTS

The 2 groups were similar in mean age and weight at surgery. Mean operative time was significantly shorter in the open surgery vs the laparoscopy group (96 minutes, range 50 to 150 vs 219, range 140 to 310, p <0.0001). Mean postoperative use of acetaminophen (1.9 vs 3.22 days, p = 0.03) and morphine derivatives (1.9 vs 3.06 days, p not significant) was less in the laparoscopy group. Mean hospital stay was shorter in the laparoscopy group than in the open surgery group (2.4 days, range 1 to 5 vs 5, range 3 to 7, p <0.0001). Mean followup was 21 (range 12 to 51) and 24 months (range 12 to 60) in the open and laparoscopy groups, respectively.

CONCLUSIONS

The operative time of laparoscopic pyeloplasty remains significantly longer than that of the open procedure in children. The main advantage of the laparoscopic approach is that it significantly decreases hospital stay compared with that after an open procedure. Although in our study analgesic use was less after laparoscopy, our results should be confirmed by a prospective, randomized study.

Comparison of retroperitoneal laparoscopic and open nephrectomy for benign renal diseases in children

OBJECTIVES

To compare the results of retroperitoneal laparoscopic versus open nephrectomy for benign renal diseases in children.

METHODS

From January 1999 to February 2003, retroperitoneal nephrectomy or nephroureterectomy was performed in 23 consecutive children (7 girls and 16 boys). The median patient age was 4 years (range 1 to 13). The disease was on the right side in 9 children and on the left side in 14. Operative and convalescence parameters, including operative time, blood loss, transfusion rate, resumption of oral intake, hospital stay, and complication rate, were evaluated in both groups.

RESULTS

All laparoscopic cases were completed successfully without conversion to open surgery. The median operative time and estimated blood loss were not statistically different between the two groups. No major perioperative complications occurred in any child, but a wound site complication occurred in 1 child who had undergone open surgery. The median hospital stay of the open group was 4 days (range 3 to 14), significantly longer than that of the laparoscopic group (median 2.5 days, range 2 to 6; P = 0.018). The cosmetic results of the laparoscopic group were excellent; the scars from the trocar sites were barely discernible at the initial postoperative visit. Convalescence was uneventful in all patients.

CONCLUSIONS

Retroperitoneal laparoscopic nephrectomy and nephroureterectomy may be performed for benign disease in children with minimal morbidity, improved cosmetic results, and a short hospital stay. Our findings indicate that retroperitoneal laparoscopic nephrectomy is appropriate in children and superior, in some instances, to open surgery.

Hemodynamic and respiratory effect of pediatric urological laparoscopic surgery: a retrospective study

PURPOSE

We investigate the impact of extraperitoneal and intraperitoneal CO2 insufflation on cardiopulmonary variables in children undergoing laparoscopic surgery.

MATERIALS AND METHODS

The records of 73 patients who underwent laparoscopic urological surgery between December 2000 and April 2002 were retrospectively reviewed. Data collection included respiratory rate (RR), peak airway pressure (PAP), O2 saturation, end tidal CO2 (ETCO2), heart rate, systolic and diastolic blood pressure, electrocardiogram and insufflation pressure. All variables were recorded before and after CO2 insufflation. Only patients with complete records were included in the analysis.

RESULTS

The study included 62 participants. Of the patients 16 boys and 13 girls with a mean age +/- SD of 7.2 +/- 5.1 years underwent extraperitoneal surgeries, 14 partial or total nephrectomy and 5 pyeloplasty. Mean retroperitoneal CO2 insufflation pressure was 12.1 +/- 1.5 mm Hg and mean operative time was 3.6 +/- 1 hours. We operated on 13 children on the right and 16 on the left decubitus lateral position. Significant increase in ETCO2, RR and PAP was recorded after CO2 insufflation in the extraperitoneal group. Use of the left lateral position resulted in a significant increase in ETCO2 (37.1 +/- 3.6 vs 40 +/- 3.8, p = 0.04) after CO2 insufflation compared to the right decubitus lateral position. Transperitoneal surgery was performed in 32 boys and 1 girl with a mean age of 3.8 +/- 4.1 years for cryptorchidism (32) and attempted pyeloplasty (1). Mean intraabdominal CO2 insufflation pressure was 11 +/- 2.4 mm Hg and mean operative time was 1.7 +/- 0.8 hours. A significant increase in RR (16.5 +/- 3.1 vs 17.9 +/- 3.4, p = 0.0002) and PAP (13.2 +/- 4.8 vs 16.1 +/- 5.7, p <0.0001), and a decrease in O2 saturation (99.6 +/- 0.6 vs 98.7 +/- 7.1, p = 0.0003) and heart rate (116 +/- 19 vs 113 +/- 18, p = 0.019) were recorded after CO2 insufflation.

CONCLUSIONS

Our study documented significant hemodynamic and respiratory changes during pediatric laparoscopic surgeries. A similar effect on the respiratory parameters was observed in both groups. Although there were no apparent complications associated with either approach, further prospective studies are warranted to confirm the effect of laparoscopic urological surgery on cardiopulmonary function in children.

Laparoscopic adrenal surgery for neuroblastomas in children

PURPOSE

The role of laparoscopy in children with neuroblastomas has not been fully defined. The laparoscopic approach to the adrenal gland is already largely used in adults and a few cases have been reported in children. We report the experience of a single surgical team center with laparoscopic adrenal surgery for neuroblastomas in children.

MATERIALS AND METHODS

Between September 2000 and October 2002 laparoscopic adrenalectomy for neuroblastoma was performed in 9 patients (6 girls and 3 boys) with a mean age of 38 months (range 2 months to 9 years). Two tumors were detected prenatally and 7 postnatally. Preoperative diagnosis was neuroblastoma stage I in 4 cases and stage IV in 3 cases, and nondetermined suprarenal calcified masses in 2 cases. A 4 or 5-trocar transperitoneal approach was used in all cases. The adrenal tumors were completely excised, placed into a plastic bag and removed through the umbilical trocar site.

RESULTS

All of the adrenal tumors were well encapsulated and completely excised. One of the 9 procedures was converted to open surgery because of adhesions to renal vessels. In 1 case a second hepatic localization was removed simultaneously, and in 3 cases 1 or more lymph nodes were resected. Average operative time was 85 minutes (range 45 to 170). There were no deaths. There were no postoperative complications, except 1 port site infection that was treated locally. Blood transfusion was not required. Average hospital stay was 4.5 days (range 2 to 10). Histological analysis of the 9 specimens (maximum length 6 cm) confirmed the diagnosis of neuroblastoma. N-myc status was studied in 8 of the 9 resected neuroblastomas and was amplified in 2 cases (both stage IV with preoperative biopsy). Average postoperative followup was 15 months (range 1 to 25). There was no local recurrence or metastasis, except in the case that required conversion to open surgery (local recurrence 7 months later).

CONCLUSIONS

Laparoscopic adrenalectomy for neuroblastoma is safe and feasible in children, with good results. Experience with advanced laparoscopic surgery is required to achieve this result in optimal oncological conditions. Our short-term results must be reevaluated at long term, and further studies are needed to compare laparoscopy to open surgical techniques.

Paediatric laparoscopic surgery

PURPOSE OF REVIEW

Laparoscopic procedures in paediatric urology are gaining popularity, with an increasing number of centres performing advanced surgery. Indications have expanded from diagnostic to ablative surgery and more recently to reconstructive procedures. The current status of the indications and results of different laparoscopic procedures dealing with paediatric urology are reviewed.

RECENT FINDINGS

Laparoscopic orchiopexy for intra-abdominal testis gives better results than classic open surgery procedures. Palomo modified varicocelectomy with lymphatic preservation is the optimal surgical procedure to treat varicocele in adolescents. The retroperitoneal approach to renal surgery is gaining popularity. Total and partial nephrectomies are feasible in comparable operative times with open surgery and shortened hospital stays. Dismembered pyeloplasty remains a challenging procedure limited to few centres, with excellent midterm results. Laparoscopic adrenal surgery has been extended to neuroblastoma in selected cases. Laparoscopic transvesical ureteric re-implant is now feasible, and opens a new era in bladder surgery. Finally, results of the initial experience with robot-assisted pyeloplasty are now available in children, and showed similar results with regard to the postoperative course, but shorter operative times with experience.

SUMMARY

The value of laparoscopic orchiopexy for intra-abdominal testis and ablative surgery such as total and partial nephrectomy and adrenalectomy has been confirmed. Robot-assisted laparoscopic surgery will probably popularize challenging procedures such as pyeloplasty and ureterovesical re-implant, which are still limited to a few centres. Despite an increase in the number of publications dealing with the results of laparoscopic procedures, efforts are still needed to validate the benefits of such procedures over open surgery.

Laparoscopic dismembered pyeloplasty by a retroperitoneal approach in children

OBJECTIVES

To report our experience with dismembered laparoscopic pyeloplasty by a retroperitoneal approach in children with pelvi-ureteric junction (PUJ) obstruction.

PATIENTS AND METHODS

Between 1999 and 2002, retroperitoneal laparoscopic dismembered pyeloplasty was attempted in 21 children (one bilateral; mean age 8 years, range 1.7-17). In a flank position with four ports (one of 5 or 10 mm and three of 3 mm), the PUJ was resected and the anastomosis made using 6/0 absorbable sutures. Any redundant renal pelvis was reduced when needed. A JJ stent was inserted in all patients.

RESULTS

The procedure could not be completed by laparoscopy in four patients, the main reason being difficulty in completing the anastomosis; in the other 18 patients the procedure was successful. An aberrant crossing vessel was found in nine patients and dismembered pyeloplasty enabled ureteric transposition in all, with no conversion. The mean (range) operative duration was 228 (170-300) min and the mean hospital stay 2.5 (2-4) days. In three patients the JJ stents were not in the bladder at the time of removal by cystoscopy, and ureteroscopy was used to retrieve them. All children returned to full activities within 7 days of surgery. The mean (range) follow-up was 12.7 (2-36) months, with six children followed for> 2 years; all were asymptomatic, with imaging confirming improved hydronephrosis.

CONCLUSIONS

These mid-term results confirm that retroperitoneal laparoscopic dismembered pyeloplasty is a safe and feasible approach in children. Although the technique is very demanding it has the advantage of duplicating the principles of the open approach. The long operative duration and high conversion rate might be reduced with experience. Before expanding this approach to younger children, refinements in the anastomotic technique are needed.

Retroperitoneal laparoscopic vs open partial nephroureterectomy in children

OBJECTIVES

To compare the results of retroperitoneal laparoscopic with open partial nephroureterectomy.

PATIENTS AND METHODS

Laparoscopic retroperitoneal partial nephroureterectomy was undertaken in 15 children (13 upper and two lower poles; median age at the time of surgery 61 months, range 5-212). A three-trocar retroperitoneal approach was used. The polar vessels were identified and either coagulated or clipped before transecting the parenchyma using a harmonic scalpel. An additional 13 consecutive children underwent similar procedures (11 upper and two lower poles) by conventional open surgery (median age at surgery 16 months, range 1.5-72).

RESULTS

One patient in the laparoscopy group required conversion to open surgery because of a peritoneal tear and was excluded from the analysis. The mean (range) operative duration was 146 (50-180) and 152 (75-240) min for the open surgery and laparoscopy groups, respectively. The blood loss was minimal (< 20 mL) in both groups. The mean (range) hospital stay was 1.4 (1-3) and 3.9 (3-5) days for the laparoscopy and open groups, respectively (P < 0.001). Eight patients were discharged on the day after the laparoscopic procedure. In addition, of those patients in the laparoscopy group who had a lower-pole partial nephrectomy, one had a urinoma after surgery.

CONCLUSION

Laparoscopic retroperitoneal partial nephrectomy is a safe and feasible procedure in children. It requires a similar operative duration to that of an open procedure. The main advantage to the laparoscopic approach is that it significantly decreases the hospital stay compared with that after an open procedure.

Posterior approach for retroperitoneal laparoscopic bilateral nephrectomy in a child

We report on a unique posterior approach for bilateral nephrectomy by retroperitoneoscopy that was conducted in a 13-year-old boy with end-stage renal disease managed by peritoneal dialysis. A posterior approach for bilateral nephrectomy by retroperitoneal laparoscopy provided adequate visualization and created enough working space for the manipulation. The procedure was performed during a short period, and the patient did not need to be repositioned. Retroperitoneal laparoscopic bilateral nephrectomy is a useful option in school-aged children with poorly functioning kidneys, particularly those children also undergoing peritoneal dialysis.

Laparoscopy in pediatric urology

Laparoscopy in pediatric urology is a rapidly evolving field that is becoming part of the operative repertoire of an increasing number of pediatric urologists. This article summarizes the latest ideas and issues in the expanding field of laparoscopy in pediatric urology. New methods of obtaining laparoscopic access and retraction are discussed. Laparoscopic experiences in urologic reconstruction, diagnosis and treatment of the nonpalpable testis, renal surgery, ureteral reimplantation, varicocelectomy, hydrocelectomy, and herniorrhaphy are reviewed. Articles assessing the safety of a pneumoperitoneum in patients with a ventriculoperitoneal shunt are also discussed.