Diagnosis and long-term outcome of renal cysts after laparoscopic partial nephrectomy in children

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.

[Kidney Cysts and Cystic Nephropathies in Children - A Consensus Guideline by 10 German Medical Societies]

This consensus-based guideline was developed by all relevant German pediatric medical societies. Ultrasound is the standard imaging modality for pre- and postnatal kidney cysts and should also exclude extrarenal manifestations in the abdomen and internal genital organs. MRI has selected indications. Suspicion of a cystic kidney disease should prompt consultation of a pediatric nephrologist. Prenatal management must be tailored to very different degrees of disease severity. After renal oligohydramnios, we recommend delivery in a perinatal center. Neonates should not be denied renal replacement therapy solely because of their age. Children with unilateral multicystic dysplastic kidney do not require routine further imaging or nephrectomy, but long-term nephrology follow-up (as do children with uni- or bilateral kidney hypo-/dysplasia with cysts). ARPKD (autosomal recessive polycystic kidney disease), nephronophthisis, Bardet-Biedl syndrome and HNF1B mutations cause relevant extrarenal disease and genetic testing is advisable. Children with tuberous sclerosis complex, tumor predisposition (e. g. von Hippel Lindau syndrome) or high risk of acquired kidney cysts should have regular ultrasounds. Even asymptomatic children of parents with ADPKD (autosomal dominant PKD) should be monitored for hypertension and proteinuria. Presymptomatic diagnostic ultrasound or genetic examination for ADPKD in minors should only be done after thorough counselling. Simple cysts are very rare in children and ADPKD in a parent should be excluded. Complex renal cysts require further investigation.

Long-Term Follow-Up of Laparoendoscopic Single-Site Partial Nephrectomy for Nonfunctioning Moieties of Renal Duplication and Fusion Anomalies in Infants and Children

Objectives: To report on long-term follow-up and outcomes of infants and small children who have undergone laparoendoscopic single-site (LESS) partial nephrectomy to manage upper urinary tract duplication and fusion anomalies. Materials and Methods: A retrospective review was performed evaluating outcomes of pediatric patients who underwent LESS partial nephrectomy for upper urinary tract duplication and fusion anomalies from January 2012 to July 2015, by a single surgeon at a tertiary pediatric referral center. Demographic and perioperative data were reviewed as well as follow-up imaging. Descriptive statistics were used for analysis. Results: A total of 18 patients were identified. Additional access was used for two patients to complete the procedure. Median follow-up was 39 months. No short-term complications were encountered. Three patients were noted to have abnormal postoperative ultrasounds: two perinephric fluid collections and one atrophy of the remaining ipsilateral moiety. One fluid collection resolved completely, and the other decreased in size. Complete atrophy of the ipsilateral moiety occurred. No secondary procedures were required. Conclusions: LESS partial nephrectomy is safe for renal duplication and fusion anomalies with good long-term outcomes. Although it can be safely performed, it is a technically demanding procedure and has been discontinued in favor of robotic partial nephrectomy.