Feasibility of Pediatric Laparo-Endoscopic Single-Site Partial Nephrectomy in Infants and Small Children
abstract
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Access this abstract now Full Text Available for ClinicalKey SubscribersOBJECTIVE
To assess the feasibility and outcomes of laparo-endoscopic single site (LESS) partial nephrectomy (PN) in infants and small children for upper urinary tract duplication anomalies.
MATERIALS AND METHODS
The medical records of all patients undergoing LESS PN at a single pediatric institution were retrospectively reviewed for patient demographics, perioperative details, and outcomes. A cystoscopy was initially performed to place an externalized catheter into the ureter of the ipsilateral normal renal moiety. An Olympus TriPort, an Olympus Endoeye flexible tip laparoscope, standard 3- or 5-mm instrumentation, and a LigaSure Blunt were utilized.
RESULTS
Four children (two boys, two girls) underwent LESS PN. Three patients underwent upper pole PN and one underwent lower pole PN. All procedures were performed for poorly functioning obstructed renal moieties (one ureterocele, one ureteropelvic junction obstruction and vesicoureteral reflux, and two ectopic ureters). Median age was 6.2 months (range 2.5-16.4 months). Median weight was 7.7 kg (range 6.1-12.6 kg). Median operative time was 126 min (range 97-180 min). No patient received inpatient postoperative narcotics. Median follow-up was 9.9 months (range 6.2-19.1 months). No postoperative complications were noted. Postoperative renal ultrasound demonstrated successful resection in all patients.
CONCLUSIONS
LESS PN is technically feasible, safe, and effective for upper urinary tract duplication anomalies in infants and small children.
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Pediatric Laparo-Endoscopic Single Site Partial Nephrectomy: Feasibility in Infants and Small Children for Upper Urinary Tract Duplication Anomalies
J Pediatr Urol 2014 Oct 01;10(5)859-863, D Bansal, NG Cost, CM Bean, PH NohFrom MEDLINE®/PubMed®, a database of the U.S. National Library of Medicine.
With the ongoing advancement of endoscopic surgery in pediatric urology, surgeons continue to explore new and better tools to limit surgical morbidity. This tendency is the basis of all advancements in surgical practice and it must be supported. This report presents the application of single-site techniques for laparoscopic surgery as applied to partial nephrectomy in small children. The procedure was successfully completed without complication and with reasonable operative times in 4 patients. Single-site techniques have been used in several pediatric applications with the aim of reducing postoperative pain and improving cosmesis.
However, as we continue our steady advancement in surgical tools and techniques, we need to sharpen our analytic tools and avoid making assumptions for our patients and their families. This is relevant to this report in several ways. First, the claim of feasibility based on 4 cases is of limited value. What we really do not know is how effectively this method could be disseminated to general use with acceptable safety and efficiency. The surgical endpoint was assessed with ultrasound to ensure successful resection of diseased renal moieties. This does not address the critical question on pediatric partial nephrectomy as to the health of the remnant pole. Doppler ultrasound is well-suited to assess this, which should be a standard postoperative study. No fluid collections were identified, which is reassuring; yet, in the modern literature of laparoscopic partial nephrectomy, there is a reasonable frequency of postop fluid collections when the polar defect is not closed. While these are rarely clinically significant, they significantly bother parents. Suturing these defects closed may be difficult with the laparoendoscopic single-site techniques.
Second, the assumption that one large umbilical incision is cosmetically preferable to two small abdominal incisions is unproven. Thirdly, the assumption that one larger incision is less painful postoperatively than three small incisions is also unproven. We are not even sure what the real basis of pain is after laparoscopic surgery. It may reflect abdominal distention more than the incisions. Finally, the assessment of pain in infants is notably difficult and simply indicating whether pain medication was administered or not is a very limited assessment of postoperative morbidity.
As we move forward, we will need to ensure that assumptions about important clinical parameters are not made without validation. To validate our assessments, a major effort is needed to develop effective and robust tools to assess postoperative pain and the metabolic changes induced by surgery, as well as the perceptions and preferences of our patients and their families. Without these sharper tools, we will continue to read feasibility studies of what is possible, without learning what is best for our patients.