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312 Laparoscopic Paediatric Urology
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Figure 23.2 Da Vinci system (the console in the left and the robot in the right).
two sizes: 8 and 5 mm. e 8-mm instruments
articulate with a pitch-roll-yaw mechanism,
whereas the 5-mm instruments articulate in a
ʻserpentineʼ manner. e Da Vinci instruments
provide seven degrees of freedom in movement.
e lack of commercially available 3-mm instruments combined with the minimum 8 cm distance between each port precludes the use of the
robot in neonates.
CURRENT INDICATIONS FOR
MINIMALLY INVASIVE SURGERY
IN PAEDIATRIC UROLOGY
Laparoscopic Nephrectomy
In centres where the expertise is available, minimally invasive surgical techniques have largely
replaced open nephrectomy and nephro ureterectomy. e transperitoneal route has the advantage
of a larger working space, whereas the retroperitoneoscopic approach obviates the need for colonic
mobilisation and avoids the risks of injury to
hollow viscera and the potential for adhesion formation. However, the combination of reversed orientation of the kidney and hilum with the patient
in a semiprone or prone position and the comparatively smaller working space make the retroperitoneoscopic approach more dicult to master.
Regardless of which approach is adopted, laparoscopic nephrectomy and nephroureterectomy
oer undoubted benets to the child in terms of
faster postoperative recovery and improved cosmesis by comparison with open surgery.
Indications
●
Congenital dysplastic kidney
●
Multicystic dysplastic kidneys (MCDK) – see
Chapter 10
●
Pelviureteric junction (PUJ) obstruction with
severe loss of function
●
Reux-associated nephropathy
●
Intractable protein loss associated with con-
genital nephrotic syndrome
●
Native nephrectomy prior to renal
transplantation
Operative technique for
retroperitoneoscopic nephrectomy
e operating theatre layout for retroperitoneoscopic nephrectomy is shown in Figure 23.3. e
patient is positioned prone, with the chest and
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Figure 23.5 Schematic representation of port
Figure 23.3 Theatre layout for left retroperi-
toneoscopic nephrectomy, with patient (P) in
prone position: monitor and stack system (AV),
theatre nurse (N), operating surgeon (S), assistant (A) and instrument table (I).
position for SIMPL nephrectomy. If required,
a second instrument port can also be placed
through the sacrospinalis muscle in a position
medial to the camera port site.
pelvis raised to allow the abdomen to be dependent
(Figure 23.4). Topographic landmarks and anticipated port sites are marked as shown in Figure 23.5.
rough a small incision between the iliac
crest and the tip of the 12th rib a small area of the
retroperitoneum is dissected bluntly with artery
forceps to allow the insertion and ination of a
balloon to create a retroperitoneal working space,
which is then insuated with CO2 via a Hasson
cannula. An instrument port is placed under
Figure 23.4 Patient positioned for right retro-
peritoneoscopic nephrectomy.
direct vision below the tip of the 11th/12th ribs
and above the iliac crest.
Following incision of Gerota’s fascia, the kidney is dissected on its posteromedial aspect to
expose the hilar vessels, which are individually
identied and divided between haemoclips or
with a harmonic scalpel. e ureter is traced inferiorly as far as necessary and is then divided. If
there is reux into the ureter it is ligated before
being divided or alternatively the bladder is
drained with a urethral catheter for 48 hours.
Small kidneys can be removed directly via the
camera port, whereas larger kidneys may require
entrapment in an Endopouch retrieval device and
piecemeal removal.
Results
A systematic review of the literature found that
whilst the overall results of transperitoneal (TP)
and retroperitoneoscopic (RP) nephrectomy were
broadly similar, recovery was faster aer RP
nephrectomy – which also had a lower conversion
rate (<3%) and fewer complications. Because the
peritoneum remains intact during RP nephrectomy, this approach is particularly suitable for
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performing bilateral nephrectomy in children with
end-stage renal disease since postoperative peritoneal dialysis can be performed immediately– thus
obviating the need for a period of haemodialysis.
Unlike transperitoneal nephrectomy the retroperitoneoscopic approach has the advantage of
enabling the entire procedure to be performed
with a single instrument port. In the authors’
institution the single instrument port laparoscopic
technique nephrectomy (SIMPL) has been used
successfully to perform over 150 nephrectomies in
patients ranging from 1 month to 18 years of age
(Figure 23.5).
Laparoscopic Heminephrectomy
Minimally invasive surgery has been widely used
to perform heminephrectomy and the results
are comparable to open surgery, even in small
infants. e indications relate mainly to renal
duplication anomalies.
Upper pole heminephrectomy. is is the most
commonly performed procedure. e anatomy is
typically characterised by dilatation of a poorly
functioning upper pole renal moiety in conjunction with a d ilated upper pole ureter. Laparoscopic
heminephrectomy is also used to remove a poorly
functioning upper pole, which is accompanied by
an ectopic ureter causing incontinence in girls.
Lower pole heminephrectomy. is is mostly
performed to remove a poorly functioning lower
pole renal moiety in cases of reux-associated
nephropathy or, rarely, lower moiety PUJ obstruction with loss of function.
e laparoscopic dissection may prove difcult in children with a history of recurrent or
recent UTI’s which have given rise to dense adhesions between the kidney, the ureter and the peritoneum. In such cases, an open approach may
be preferable for technical reasons and to avoid
excessive excessive blood loss.
Operative technique for
retroperitoneoscopic
heminephrectomy
e initial steps are the same as for a retroperitoneoscopic nephrectomy. Care is taken to establish
the anatomy of the kidney and dupex ureters and
to identify the blood vessels supplying both renal
moieties. Following division of the blood vessels
supplying the aected moiety, the ureter draining
this moiety is carefully mobilised from the ureter
which is being preserved before being divided.
Pallor of the renal parenchyma following division
of the blood vessels to the aected moiety serves
to demarcate it from the healthy moiety. e
kidney is then transected between the two moieties using monopolar diathermy, ligasure or an
endoloop (Figure 23.6). e distal ureteric stump
is traced as far as possible down into the pelvis
before being removed – with care being taken to
visualise and safeguard the remaining ureter.
Results
Conventional transabdominal laparoscopy has
become the ʻgold standardʼ technique for hemi-
nephrectomy in children. Retroperitoneoscopic
heminephrectomy is a challenging procedure
with long learning curve, especially for lower pole
heminephrectomy. However, it oers the advantages of direct visualization of the duplex kidney,
decreased risk of intra-abdominal adhesions and
a shorter hospital stay.
Laparoscopic Pyeloplasty
Laparoscopic pyeloplasty was initially introduced
for the management of PUJ obstruction in older
children but despite being more technically challenging in infants, it has also been adopted in
many centres as the modality of choice in young
children and infants (including those under 6
months of age).
Indications
●
Symptomatic PUJ obstruction
●
Worsening hydronephrosis on serial imaging
●
Ultrasonographic ndings of signicant
hydronephrosis (pelvic anteroposterior
[AP] diameter >20 mm with calyceal dilatation) and reduced dierential renal function
(<4 0 %)
●
Ultrasonographic ndings of severe hydronephrosis (pelvic AP diameter >30 mm with
calyceal dilatation)
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Operative technique for
laparoscopic pyeloplasty
Laparoscopic pyeloplasty can be performed via
the transperitoneal or retroperitoneoscopic route.
Although there is no particular advantage of one
approach over the other, the authors’ preference
is for the transperitoneal route since it provides a
relatively larger working space for intracorporeal
suturing.
e child is positioned in a lateral decubitus
position with the aected kidney uppermost.
e camera port is placed in the region of the
umbilicus and two working ports are inserted:
one under the costal margin and the other in
the ipsilateral iliac fossa. e kidney is identied either by reecting the colon medially or
through a transmesenteric window. Once the
pelvi ureteric junction has been visualised, the
renal pelvis is stabilised with a ‘hitch stitch’
through the abdominal wall. A dismembered
pyeloplasty is then performed – with excision
of redundant renal pelvis if required. A length
of proximal ureter is ‘spatulated’ and anastomosed to the lower end of the open renal
pelvis (Figure 23.7). e posterior wall of the
anastomosis is performed with a continuous
absorbable suture. A JJ stent is introduced and
passed antegradely down to the bladder over a
guidewire before completion of the anstomosis
Figure 23.6 Intraoperative images of retroperi-
toneoscopic heminephrectomy. (a) Upper pole
heminephrectomy using endoloop; (b) and (c)
lower pole heminephrectomy using ligasure.
Contraindications for laparoscopic pyeloplasty
include a small extrarenal pelvis, previous renal
surgery and anatomical variants, such as a horseshoe kid ney.
Figure 23.7 Intraoperative view of laparoscopic
left pyeloplasty. The renal pelvis is stabilised
with a ‘hitch stitch’ through the lateral abdominal wall (top right corner).
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with a further continuous absorbable suture. A
urethral catheter is le in situ for a minimum
period of 48 hours or until the patient is fully
mobile. e stent is removed cystoscopically
aer a period of 4 weeks. As an alternative to
using a JJ stent the authors prefer to protect
the anastomosis and drain the kidney postoperatively with a ‘nephrostent’, which drains
externally. is overcomes the complications
associated with an indwelling JJ stent and
can be removed without the need for a second
procedure.
Laparoscopic pyeloplasty is a safe and eective
operation in children and numerous studies have
found that outcomes are comparable to those
achieved by open pyeloplasty.
Robotic Pyeloplasty
Robotic pyeloplasty is based on the same concepts as laparoscopic pyeloplasty. e patient
is placed in the lateral decubitus position with
the operative side facing up and slightly rotated
from the vertical plane. To maximize the range of
movement for the robotic arms, the child is positioned as close to the edge of the operating table
as possible. e port placements for a robotic
pyeloplasty are illustrated in Figure 23.8. Care
is taken to ensure that the ports are separated by
at least 6–8 cm to maximize robotic arm movements. If necessary, an additional port is used to
facilitate passage of sutures, suctioning, and/or
retraction of the liver when operating on the right
kidney. Following port placement, and ʻdockingʼ
of the robot, the dilated renal pelvis is identied
and the procedure is performed using the same
steps as those performed during conventional
laparoscopy.
In one large, single centre study, 98% of
robotic-assisted laparoscopic pyeloplasty (RALP)
were performed by a transperitoneal approach
with an operating time averaging 199 minutes.
e overall success rate was 96%. A comparative study of open, conventional laparoscopy
and robotic-assisted pyeloplasty found no difference in success rates between these three
modalities. However, RALP was associated
with reduced analgesic requirements and shorter
hospital stay.
Figure 23.8 Right robotic-assisted laparoscopic
pyeloplasty (with crossing vessels at PUJ level).
Laparoscopic ‘Vascular Hitch’
Antenatally detected hydronephrosis is usually associated with some form of intrinsic
obstruction at the pelvi ureteric junction with
lower pole crossing vessels being present in only
6–11% of cases. By contrast, lower pole vessels
are found in 50–60% of cases of PUJ obstruction in older children and adults. When the
presence of crossing vessels is identied during
pyeloplasty, the conventional approach has been
perform a dismembered pyeloplasty in which
the vessels are re-positioned so they lie posterior to the completed anastomosis. If, however,
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there is no evidence of intrinsic obstruction at
the time of surgery and if the obstruction can
be attributed to extrinsic compression of the
PUJ by crossing lower vessels, a vascular hitch
procedure can be considered as an alternative to
dismembered pyeloplasty. In this procedure, the
lower pole vessels are relocated away from the
PUJ and anchored in more cranial position on
the anterior wall of the renal pelvis (Figure 23.9).
e principal candidates for this procedure are
older children who present with intermittent
episodes of pain and who have no preceding history of antenatal hydronephrosis. e vascular
hitch procedure avoids the need to transect the
pelvis and therefore minimises the risk of any
postoperative urinary leak. It is also less technically demanding than laparoscopic pyeloplasty,
carries a lower complication rate and results in a
shorter hospital stay. A recent multicentre study
found that with appropriate patient selection,
the vascular hitch procedure oers can excellent long-term outcomes – as evidenced by 100%
resolution of symptoms, decreased hydronephrosis grade and improved drainage on MAG3
renogram.
Laparoscopic Adrenalectomy
Laparoscopic adrenalectomy is now widely
regarded as the optimal surgical procedure for
removing the adrenal gland. Since the initial
report of laparoscopic adrenalectomy in 1992, the
technique has evolved to become a safe and eective means of removing benign and malignant
adrenal tumours in both adults and children.
Although the transperitoneal approach is used
more widely, the retroperitoneoscopic approach
oers distinct advantages particularly for paediatric urologists who already familiar with this
approach for renal surgery. Despite developments
in technique, however, laparoscopic adrenalectomy remains a challenging surgical undertaking
urgery – particularly in view of the paramount
importance of avoiding capsular breach and
tumour spillage.
Figure 23.9 Laparoscopic ʻvascular hitchʼ.
Indications
●
Phaeochromocytoma
●
Adrenal adenoma
●
Adrenocorticotrophic hormone (ACTH)dependent Cushing’s syndrome
●
Neuroblastoma
Contraindications include; previous renal surgery, large tumours exceeding 8 cm in diameter,
evidence of tumour thrombus within the adrenal
vein and/or inferior vena cava (IVC) coagulation
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disorders and a suspected diagnosis of adrenal
carcinoma.
Preoperative assessment
A detailed ultrasound scan of the adrenal glands
can provide valuable information on the location and size of a mass, and whether it is cystic or
solid. In selected cases, the use of Computerised
Tomography (CT) and Magnetic Resonance
Imaging (MRI) can also be very informative
(Figure 23.10). Some conditions aecting the adrenal glands (notably ‘central’ Cushing’s syndrome)
are associated with bilateral diuse enlargement
rather than a focal lesion.
Imaging is also valuable in establishing
whether there is intravascular extension into the
adrenal vein and/or IVC since this information
will help to determine the suitability of a laparoscopic approach and the safest approach for
specimen retrieval.
Children with hypertension caused by phaeochromocytoma receive 7 days preoperative administration of α-blockers, such as phenoxybenzamine,
to which β-blockers, such as propranolol may be
added to decrease the risk of tachyarrhythmias.
Operative technique for
retroperitoneoscopic
adrenalectomy
e child is positioned fully prone in a similar
manner to a retroperitoneoscopic nephrectomy
and the same landmarks and access technique are
used to enter the retroperitoneum.
e dissection commences around the kidney
and continues until the inferior margin of the
adrenal gland is visualised at the superomedial
border of the kidney. e arterial blood supply
to the adrenal is then identied and divided. To
minimise bleeding from the surface of the gland,
dissection is performed in a plane within the
surrounding adipose tissue. Le adrenalectomy
is more dicult than right adrenalectomy due
to the smaller size of the gland and adrenal vein
and the lack of clear landmarks, such as the inferior vena cava. Once the veins have been divided
and adrenal has been fully mobilised it is placed
within an endobag and removed through the
camera port incision.
Opinion remains divided on whether the
transperitoneal or retroperitoneoscopic approach
is preferable. ere are no reliable comparative
data in children and most reports have consisted
of small series. e authors’ have performed more
than 30 RP adrenalectomies, with excellent intraoperative haemodynamic stability and complete
excision of lesions in every case.
Figure 23.10 CT scan showing left cystic phaeo-
chromocytoma in an 8-year-old male child.
Other Techniques
Laparoscopic ureteric
reimplantation
Although open ureteric reimplantation (with
either the intravesical or extravesical approach)
remains the most widely performed surgical
approach to the correction of vesico ureteral
reux, the use of minimally invasive surgery
has also been reported. e techniques which
have been deployed include; vesicoscopic ureteral reimplantation using the Cohen technique
and laparoscopic or robotic-assisted extravesical
ureteral reimplantation using the Lich-Gregoir
technique).
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In the vesicoscopic technique, the bladder is
insuated with CO2 to create a pneumovesicum.
e reuxing ureter is mobilised in a similar manner to the technique for open reimplantatation
and is then reimplanted using a cross-trigonal
submucosal tunnel. e limited published data
indicate that this is a safe and eective technique,
with success rates comparable to conventional
open anti-reux surgery and a lower incidence of
postoperative bladder spasms.
Laparoscopic extravesical ureteral reimplantation also has a high success rate and has been
reported to oer superior cosmetic outcomes and
reduced postoperative morbidity by comparison
with open surgery in the older children. As with
open extravesical ureteral reimplantation the
laparoscopic technique has been reported to carry
some risk of damage to pelvic innervation – with
consequent bladder dysfunction leading to urinary retention and constipation.
Laparoscopy in disorders of sex
development
Laparoscopy plays a valuable role in the investigation and management of children with DSD
by permitting direct visualisation of the internal
genital anatomy including the uterus, Müllerian
duct remnants, gonads and vasa deferentia.
Laparoscopy also provides an opportunity to
perform gonadal biopsies where indicated and to
remove dysgenetic gonads or gonads, which are
discordant with the sex of rearing. Symptomatic
Müllerian duct remnants can be evaluated and
removed with relative ease.
Laparoscopic reconstructive surgery
In addition to the wide range of laparoscopic
procedures now available for complex upper
tract surgery, the use of minimally invasive
surgery has been extended to include lower
urinary tract reconstructive procedures, such
as bladder augmentation (with or without
appendico-vesicostomy) and bladder neck sling
procedures.
In a small series of young patients who had
undergone robot-assisted laparoscopic augmentation ileocystoplasty and Mitrofano procedures
the results were reported to be excellent and comparable to those achieved by open surgery. e
operating time was signicantly longer but the
duration of hospital stay was shorter and the use
of epidural anaesthesia was avoided. Diagnostic
laparoscopy is performed initially to conrm that
the length of the appendix is adequate for use in a
Mitrofano procedure prior to docking the robot.
In other respects, the technical manoeuvres are
similar to those employed in the open operation.
e evolution of robotic procedures for use in
paediatric urology will increase the availability
of alternative approaches to conventional open
reconstructive surgery – oering the prospect
of advances in patient care and improvements in
quality of life. However, the acceptance of robotic
reconstructive surgery is currently limited by the
paucity of published data and lack of randomized
controlled trials.
KEY POINTS
●
Minimally invasive alternatives to
conventional open urological procedures are now routinely practised
in major paediatric urology centres.
Indications include nephrectomy,
heminephrectomy, pyeloplasty and
adrenalectomy.
●
e relatively small size of paediatric
patients permits access to both the
upper and lower urinary tract through
the same ports. Both the transperitoneal and retroperitoneoscopic
approaches are utilised in children,
although the retroperitoneoscopic
technique is favoured for renal surgery.
●
Laparoscopic pyeloplasty is the gold
standard for older children and adolescents. e advent of robotic technology
has made intracorporeal suturing more
precise and less challenging.
●
Minimally invasive techniques have
provided new insight into disease processes and can be applied to complex
reconstructive surgery of the lower
urinary tract.
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FURTHER READING
Barashi NS, Rodriguez MV, Packiam VT,
Gundeti, MS. Bladder reconstruction with
bowel: robot-assisted laparoscopic ileocystoplasty with Mitrofanoff apendicovesicostomy in paediatric patients. J Endourol.
2018;32:119–126.
Cho A, Mushtaq I. Retroperitoneoscopic lower
pole heminephrectomy. J Pediatr Urol.
2019;15:89–90.
Esposito C, et al. Retroperitoneoscopic hemi-
nephrectomy in duplex kidneys in infants
and children: results of a multicentric
survey. J Laparoendosc Adv Surg Tech A.
2015;25:864–869.
Garg S, Gundeti M, Mushtaq I. The single instru-
ment port laparoscopic (SIMPL) nephrectomy. J Pediatr Urol. 2006;3:194–196.
Sakoda A, Cherian A, Mushtaq I. Laparoscopic
transposition of lower pole crossing vessels
(ʻvascular hitchʼ) in pure extrinsic pelviure-
teric junction (PUJ) obstruction in children.
BJU Int. 2011;108:1364–1368.
Song SH, Lee C, Jung J, Kim SJ, Park S, Park H,
Kim KS. A comparative study of paediatric
open pyeloplasty, laparoscopy-assisted
extracorporeal pyeloplasty and robot laparoscopic pyeloplasty. PLoS One. 2017;20:12.
Upasani A, Paul A, Cherian A. External stent in
laparoscopic pyeloplasty: the K-wire technique. J Pediatr Urol. 2018;14:298–299.
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Adolescent Urology
CHARLOTTE DUNFORD, CHRISTOPHER R J WOODHOUSE and DAN WOOD
Topics covered
Renal impairment
Vesicoureteric reux
Bladder exstrophy
Female genital reconstruction
Hypospadias
INTRODUCTION
e major anomalies of the genitourinary tract
are commonly reconstructed in infancy and
from a paediatric point of view the results are
generally good. However, they leave a legacy of
potential morbidity in adolescence and adult
life. Many problems are predominantly medical
or psychosocial rather than surgical in nature
and it is essential to adopt a holistic approach
to long-term care. Close collaboration between
paediatric and adolescent or adult urologists is
also important to ensure continuity of followup and specialist care. Where surgical input is
required, particularly for the revision of previous
reconstructive procedures, it may be necessary
to adopt a multi-disciplinary approach involving
gynaecological, colorectal and renal transplant
surgeons. Collaboration with a renal physician to
optimise preservation of renal function is paramount. e young patient’s transition from the
Posterior urethral valves (including transplantation)
Prune-belly syndrome
Enterocystoplasty
Spina bida
Fertility
care of paediatric specialists to the relevant adult
disciplines is of pivotal importance in determining their future engagement with follow-up and
lifelong maintenance of their renal function.
is chapter reviews the management of complex
congenital urological anomalies in the context of
their long-term outcomes and the legacy of morbidity in later life.
RENAL FUNCTION
e renal damage associated with many of the
congenital urological anomalies dates from fetal
life and despite successful correction of the structural anomaly - such as resection of posterior
urethral valves (PUV) shortly aer birth ( or even
in utero), hypertension and renal failure may
nevertheless supervene in later life. Monitoring
of renal function is therefore an integral part of
adolescent care.
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