Use of Laparoscopy in Pediatric Urology

Technique Update

TECHNIQUE UPDATE Use of Laparoscopy in Pediatric Urology Christina Kim, MD,* Steven G. Docimo, MD† *Connecticut Children’s Medical Center, University of Connecticut, Hartford, CT; †University of Pittsburgh School of Medicine, Pittsburgh, PA The goal of laparoscopy is to minimize patient morbidity while maintaining successful outcomes. The use of laparoscopy in urology has grown significantly over the past 30 years. Its use has been slower to gain acceptance in pediatrics than in the adult population. Laparoscopic orchidopexies and nephrectomies are commonly performed and have become widely accepted as alternatives to open surgery, if not the gold standard. The more technically demanding procedures, such as laparoscopic pyeloplasty, laparoscopicassisted bladder reconstruction, and laparoscopic ureteral reimplantation, tend to be performed at selected centers and have yet to achieve widespread acceptance. As laparoscopy is applied more widely in pediatric urology, its potential benefits and drawbacks will be clarified. [Rev Urol. 2005;7(4):215-223] © 2005 MedReviews, LLC Key words: Laparoscopy • Pediatric • Orchidopexy • Nephrectomy • Pyeloplasty ediatric endourology is a changing and evolving field. The optimal use of minimally invasive surgery is being explored in both adult and pediatric urology. Laparoscopy began as a diagnostic tool and now serves as a method for intricate intervention. Initially, the utility of laparoscopy was hampered by bulky equipment and limited tools. Today, technological advances have provided excellent optics and fine dissecting instruments. The benefits of laparoscopic interventions have been well defined in adults, with shorter hospitalizations and quicker P VOL. 7 NO. 4 2005 REVIEWS IN UROLOGY 215 Laparoscopy in Pediatric Urology continued returns to normal activity. Although these advantages are less obvious in the pediatric population, minimally invasive techniques are becoming increasingly important. Cosmetic advantages are more important in children than in adults, and in some cases might represent a prime indication for minimally invasive surgery. This article reviews current indications, techniques, and outcomes for commonly used pediatric laparoscopic procedures. These include laparoscopic orchidopexy, laparoscopic total and partial nephrectomy, laparoscopic pyeloplasty, laparoscopic-assisted bladder reconstruction, and laparoscopic urinary antireflux surgery. Laparoscopic Orchidopexy The incidence of undescended testis is 30% in premature infants and 3% in term infants. Twenty percent of undescended testes are nonpalpable.1 Debate continues on the best way to explore a nonpalpable testis, but laparoscopy might be the gold standard for diagnostic and therapeutic purposes. The camera port is placed through an intraumbilical incision. We prefer to place a radially dilating trocar with an open technique. An alternative is to use a 2-mm port with an in situ Veress needle introducer. In a large retrospective series, the complication rate of open access was 1.2% to 3.8%, compared with 2.6% to 7.8% for the Veress needle technique. For both techniques, the rate is related to operator experience.4,5 If the testis is intra-abdominal, it can be anywhere between the internal ring and the ipsilateral kidney. Once the testis is found, the size and distance from the internal ring are assessed. One important decision is whether a primary orchidopexy or a staged Fowler-Stephens orchidopexy will be performed. Reports have suggested that if the distance between the testis and the ipsilateral internal ring is greater than 2 cm, then clipping the vessels in preparation for a FowlerStephens orchidopexy is recommended.6 When orchidopexy is performed laparoscopically, 3 ports are placed: 1 For the nonpalpable testis, laparoscopy gives a thorough view of the testis relative to other intra-abdominal structures. It is important to perform a thorough physical examination with the patient under anesthesia before committing to laparoscopy. Eighteen percent of nonpalpable testes will become palpable when reexamined.2 In these cases, an inguinal approach is adequate, and laparoscopy is only occasionally indicated.2 However, for the nonpalpable testis, laparoscopy gives a thorough view of the testis relative to other intra-abdominal structures. In addition, it gives a magnified view of vascular supply during dissection. It might also alter the operative approach chosen.3 216 VOL. 7 NO. 4 2005 in the umbilicus and 2 just below the umbilicus along the anterior axillary line (Figure 1). To mobilize the testis, a peritoneal incision is made lateral to the spermatic vessels and toward the internal ring. The peritoneum between the vas deferens and the spermatic vessels is spared. This preserves the collateral blood supply in case the spermatic vessels either spasm or need to be divided to obtain additional length. If needed, the testicular vessels can be dissected proximal to the level of the great vessels. Before delivery of the testis into the scrotum, one measure of adequate REVIEWS IN UROLOGY Figure 1. Three ports are placed for a laparoscopic orchidopexy: 1 in the umbilicus and 2 along the anterior axillary line just below the level of the umbilicus. The umbilical port is used for the camera. The lateral ports serve as the working ports. These can be 2, 3, or 5 mm in size. Reprinted from Wu HY, Docimo SG. Orchidopexy, including laparoscopic orchidopexy. Atlas Urol Clin North Am. 2004;12:15-25. © 2004, with permission from Elsevier. length is the ability to bring the testis to the contralateral internal ring.7 The testis can be delivered into the scrotum in different ways. We prefer to pass a 2-mm grasper from the abdomen into the scrotal pouch. The grasper is usually passed over the pubis, medial to the inferior epigastric vessels and lateral to the medial umbilical ligament. If additional length is needed, the neocanal can be made medial to the medial umbilical ligament. If this route is taken, care must be exercised to avoid bladder injury. Once the 2-mm instrument is exposed through the scrotal incision, a radially dilating sleeve is passed retrograde over the instrument into the abdomen. The instrument is withdrawn, a 5- or 10-mm trocar insert is used to dilate the neocanal, and the testis is delivered directly through this trocar into Laparoscopy in Pediatric Urology its new canal. Further maneuvers to increase length can be undertaken after the testis is passed into the neocanal, as necessary. These include dividing the peritoneum over the proximal vessels or isolating the preserved distal triangle of peritoneum where the collateral vessels between the vasal and spermatic arteries are located. Testicular atrophy and malposition are the most important adverse out- been performed even in infants with excellent results.13-15 The choice of approach depends on the operator. Initial procedures were performed through a transperitoneal approach. This offers a large working space and easily identified anatomic landmarks. Three ports are generally used. The first is placed at the umbilicus, a second in the lower quadrant along the midclavicular line between Some pediatric urologists doubt the relative benefits of laparoscopic nephrectomy in younger children, whose kidneys can be removed through a small open incision and with quick patient recovery. comes of both open and laparoscopic orchidopexy. A multi-institutional analysis of laparoscopic orchidopexy outcomes suggests an overall success rate of primary, 1-stage, and 2-stage laparoscopic orchidopexies of 92%, with an atrophy rate of 6.1%.8,9 Primary laparoscopic orchidopexy with intact vessels had a success rate of 97%, 1-stage Fowler-Stephens procedures 74%, and staged laparoscopic Fowler-Stephens procedures 88%. These outcomes are more favorable than historical results for open procedures.10 Laparoscopic Total Nephrectomy Laparoscopic renal surgery for both adults and children has gained in popularity. Some well-documented advantages in adults and older children are improved cosmesis, shorter hospital stays, more rapid return to normal activities, and less postoperative pain.11,12 Some pediatric urologists doubt the relative benefits in younger children, whose kidneys can be removed through a small open incision and with quick patient recovery. We believe that there are indeed benefits to a minimally invasive approach, and laparoscopic nephrectomies have the umbilicus and the pubis, and a third in the midline or midclavicular line above the umbilicus (Figure 2). In infants, all 3 ports can be placed in the midline. Occasionally, a fourth port is used for retraction, especially of the liver edge on the right. If a retroperitoneal approach is used, the patient can be in either a lateral or prone position. When the patient is prone, the initial access is on the lateral edge of the paraspinous muscle. After dissecting between the latissimus and oblique muscles, Figure 2. Shown here is the authors’ preferred port placement for a transperitoneal laparoscopic nephrectomy. A camera is placed through the umbilical port. Along the midclavicular line, 1 working port is placed in the lower quadrant between the umbilicus and pubis. Another working port is placed in the midline between the umbilicus and the xyphoid. Reprinted from Wu HY, Docimo SG. Orchidopexy, including laparoscopic orchidopexy. Atlas Urol Clin North Am. 2004;12:15-25. © 2004, with permission from Elsevier. Gerota’s fascia is exposed and opened. This space is dilated by either blunt or balloon dissection. Additional ports are placed above the iliac crest, lateral to the paraspinal muscle and medial to the peritoneum.16 Some surgeons find the prone position advantageous because the abdominal contents fall away from the operative field, which gives clear exposure to the posterior aspect of the kidney and the renal hilum. This can be helpful in defining the upper and lower poles when a partial nephrectomy is being performed.17 Compared with the prone retroperitoneal approach, lateral positioning provides a larger working space and allows more extensive ureteral dissection. However, the kidney can fall medially and onto the renal pedicle. Constant lateral traction is needed to visualize the pedicle. Regardless of the approach used, the dissection is similar. The hilum can be approached anteriorly or posteriorly. Dysplastic or ectopic kidneys often have aberrant vasculature, so dissection should be kept close to the renal parenchyma to ensure ligation of all significant vessels. In an orthotopic kidney, dissection is generally begun at the lower pole. The ureter is exposed and isolated, and dissection is safely carried out posterior to the ureter and kidney. As the dissection progresses cranially, the hilum becomes apparent medially. The vein is anterior, and exposure of the artery might be more straightforward from a posterior approach. It is generally not difficult to separate the artery and vein from an anterior approach, however, especially if the hilum has been well exposed inferiorly. The artery should be approached proximal enough to avoid the need for division of multiple branch vessels. Once the vessels are exposed, they can be controlled with individual 5-mm clips or, if atretic, with electrocautery or VOL. 7 NO. 4 2005 REVIEWS IN UROLOGY 217 Laparoscopy in Pediatric Urology continued harmonic energy. If the veins are too large for a clip, then an intracorporeal tie might be used, resulting in a narrowing that subsequently allows clips to be placed proximally and distally.16 If the hilum is difficult to access, it can be left until the kidney has been well mobilized and divided en masse with a vascular endoscopic stapling device, with little concern for an arteriovenous fistula.18 ing segment of a duplicated system. Regardless of the approach, a primary concern is dissection of the hilum with minimal disturbance to the remaining, functioning segment. Laparoscopy might provide an advantage by minimizing the mobilization of the remaining segment and reducing vascular spasm. To identify the ureter of interest, one can look for where it crosses the Because most pediatric nephrectomies are for benign disease, there is little need to maintain the surgical margin for pathologic examination. After the hilum is divided, the kidney is usually readily separated from surrounding structures, at the level of either the renal capsule or Gerota’s fascia, depending on the reason for nephrectomy. Occasionally, a subcapsular plane must be used to remove a kidney that has infarcted or has been severely inflamed, resulting in perinephric scarring. Care must be taken to leave the adrenal gland intact and to avoid the adrenal vein on the right side as dissection of the upper pole is carried out. Once the specimen is free, it often can be removed through the 5-mm port incision. The incision might need blunt enlargement to accommodate the specimen. If necessary, the tissue can be morcellated in an extraction bag so that the port site does not have to be significantly enlarged. Because most pediatric nephrectomies are for benign disease, there is little need to maintain the surgical margin for pathologic examination. If nephroureterectomy is combined with an open lower tract reconstruction, the kidney can be removed through a Pfannenstiel incision. Laparoscopic Partial Nephrectomy In children, partial nephrectomies are usually performed for a nonfunction- 218 VOL. 7 NO. 4 2005 common iliac vessels or the medial umbilical ligament. If needed, the ureters can be followed to their origin at the renal hilum. Once the ureter is identified, it is clipped and divided. By clipping it before division, the ureter remains dilated, which can aid in dissection of the involved renal segment. Care is taken to avoid injury to the ureter to the functioning renal moiety, because that ureter might be much smaller, more difficult to see, and closely apposed to its dilated partner. The branch vessels to the nonfunctioning pole are carefully identified and ligated with clips, cautery, or the harmonic scalpel, depending on their size. Once the vessels are ligated, the ureter to the upper pole (if this is the unit being removed, which is often the case) is passed behind the main renal pedicle and used to identify the medial demarcation between the upper and lower renal units. The affected renal parenchyma can be divided with electrocautery or harmonic energy.19 To minimize bleeding, it is common to leave a small rim of the nonfunctioning segment on the remaining renal tissue. If the collecting system is left behind, it should be ablated with cautery. If there is any question of injury to the remaining REVIEWS IN UROLOGY unit’s collecting system, methylene blue can be administered intravenously or through a ureteral catheter to reveal areas of urinary leakage. In most pediatric partial nephrectomies, a drain is not required. This should be individualized according to the reason for the procedure and whether collecting system repair was required. Although simple nephrectomy, partial nephrectomy, and nephroureterectomy can all be performed through either transperitoneal or retroperitoneal approaches, many surgeons will choose a transperitoneal approach when a complete ureterectomy is necessary. Most reports of pediatric laparoscopic nephrectomies have shown a low rate of complications.10,16 Complications of primary interest are vascular and visceral injuries. Some urologists propose that a transperitoneal approach carries a greater risk of complications than a retroperitoneal approach. Studies comparing the 2 approaches show similar rates for operative time, blood loss, and hospital stay.20 There are no persuasive data to show an increased morbidity associated with either approach. Laparoscopic Pyeloplasty Laparoscopic pyeloplasty was first described in both adult and pediatric populations in 1993.21,22 There are no strict criteria to dictate when to perform laparoscopic pyeloplasties in children, and the procedure is still only available at selected centers. An ideal candidate is an older child with an extrarenal pelvis. The authors prefer a laparoscopic approach for children more than 1 year of age and an open approach for younger patients. There are multiple challenges in performing pyeloplasty in the smaller child. Most surgeons choose to leave an internal stent after laparoscopic pyeloplasties, but placing a stent in Laparoscopy in Pediatric Urology an infant carries more risk of traumatizing the delicate ureterovesical junction or the posterior anastomosis. The small diameter of the ureter makes the anastomosis technically the pubis on the side of the affected kidney (Figure 3). Retroperitoneal access often is achieved with 3 ports along the lower edge of the twelfth rib. Here we Most surgeons choose to leave an internal stent after laparoscopic pyeloplasties, but placing a stent in an infant carries more risk of traumatizing the delicate ureterovesical junction or the posterior anastomosis. difficult, especially within the confines of a small working space. On the positive side, the degree of magnification is greater than can be achieved in an open procedure, and the anatomy in the small child is conducive to laparoscopic dissection. The choice of approach is transperitoneal versus retroperitoneal. When a transperitoneal approach is used, the port placement is similar to that used for nephrectomy. One port is placed at the umbilicus, a second port in the midline superior to the umbilicus, and a third port in the midclavicular line, halfway between the umbilicus and Figure 3. Port placement for a transperitoneal laparoscopic pyeloplasty is similar to the placement for a transperitoneal laparoscopic nephrectomy. A camera port is placed through the umbilicus. One working port is placed above the umbilicus in the midline. Another working port is placed in the lower quadrant along the midaxillary line between the umbilicus and the pubic symphysis. Reproduced with permission from Peters.17 describe only the transperitoneal approach, which has the advantages of a greater working space and a more intuitive approach to crossing vessels. On the left side, we approach the uteropelvic junction (UPJ) by a transmesenteric approach. At the beginning of the procedure, cystoscopy is used to place a guidewire in the ureter. Manipulation of the wire will make the position of the ureter and UPJ evident through the mesentery. A small opening is then made in the mesentery to expose the UPJ. This avoids mobilizing the left colon, thus decreasing the amount of time and tissue disruption required for exposure. On the right side, the colon is mobilized, although the UPJ is often easily exposed behind the broad peritoneal reflection lateral and superior to the hepatic flexure. the renal pelvis and pass it through the anterior abdominal wall to steady the anastomosis. A second stay stitch placed in the ureter, though not usually needed, might help maintain proper orientation during the tailoring and suturing of the anastomosis.23 If crossing vessels are identified, the ureter is dissected posteriorly until the UPJ is seen behind the vessels. The ureter can be divided just below the UPJ. At that point, attention is turned to the anterior pelvis. As this is freed, the UPJ can be brought anterior to the vessels, where the anastomosis can be performed. The vessels themselves require no manipulation. Once the UPJ is divided, the ureter is spatulated laterally with a 3-mm scissor. The pelvis does not usually require reduction, and we generally spatulate cephalad from the UPJ rather than removing the UPJ. This gives a rounded apex, which subjectively widens the anastomosis and makes placement of the most caudal sutures technically more straightforward. The anastomosis is started with interrupted sutures at the dependent part of the renal pelvis. Fine absorbable suture is used (eg, 5-0 or 6-0 polyglactic acid suture). A small curved needle, such as a TF, is preferable. This can pass through a 3- or 5-mm port. When passing the needle, One of the biggest challenges in laparoscopic pyeloplasty is the technical difficulty of suturing a small-caliber ureter. Dissection of the UPJ is similar to the technique used in an open approach. If there are no crossing vessels, the dissection is straightforward. Once the UPJ is isolated, it is divided, leaving a tag of pelvis on the ureter. This provides a handle for manipulation during the procedure, with minimal trauma to the remaining ureter. It is helpful to place a holding stitch in it is important not to blunt the tip. The rest of the anastomosis can be done with either an interrupted or a running suture. One of the biggest challenges in laparoscopic pyeloplasty is the technical difficulty of suturing a smallcaliber ureter. This can be even more challenging when trying to sew around an internal stent. VOL. 7 NO. 4 2005 REVIEWS IN UROLOGY 219 Laparoscopy in Pediatric Urology continued A stent is placed retrograde over the previously positioned guidewire after the posterior anastomosis is completed. A double pigtail stent is left in place for 2 to 4 weeks. Patients can be managed with or without a Foley catheter for 1 night. In most cases, an external drain is not necessary.24 An alternative to stenting is placing a percutaneous nephrostomy tube. The tube can be placed under direct visualization and used to confirm postoperative success before removal. Postoperatively, our patients are observed overnight and discharged the morning after surgery with no external tubes or drains. Antibiotic fanoff continent stoma, bladder outlet procedures, and/or ureteral reimplantation. The first laparoscopic bladder augmentation was a gastrocystoplasty reported in 1995.26 Laparoscopic autoaugmentation, a technique that separates the bladder muscle from the mucosa and allows the latter to act as a compliant diverticulum, is relatively straightforward.27 However, continent diversion and enterocystoplasty have been hampered by long operative times, and long-term outcome data are limited.28 One of the biggest challenges is executing the techniques required for precise and The current state of the art in minimally invasive bladder surgery is laparoscopic-assisted reconstruction. prophylaxis is used until the stent is removed. A renal ultrasound is obtained 6 weeks after stent removal to confirm decreasing hydronephrosis, and a scan is performed only if the results are in question. Success of laparoscopic pyeloplasty in adults has been greater than 95%, which is comparable to results with an open approach.25 Reports in children have shown quicker return to normal activities than after an open procedure and comparable success.24 Pediatric laparoscopic pyeloplasty series are still few and small. Further results will serve to document the outcomes of this approach. Bladder Reconstruction A bladder that is small or poorly compliant or has intractable high-pressure contractions might require reconstruction for protection of the upper tracts or for the development of urinary continence. This commonly requires bladder augmentation with gastrointestinal tissue or ureter, with or without creation of a Mitro- 220 VOL. 7 NO. 4 2005 lengthy suturing for reanastomosis, as well as intestinal harvesting. Unfortunately, in most surgeons’ hands, autoaugmentation has not been a widely applicable long-term solution to bladder volume and compliance problems.27,29 For all of the reasons noted, the current state of the art in minimally invasive bladder surgery is laparoscopicassisted reconstruction. Laparoscopy is used to do the mobilization that would otherwise be done through the upper aspect of an open incision. Examples include mobilizing the cecum or sigmoid colon, harvesting a gastric flap, performing nephrectomy to harvest ureter, and harvesting omentum for a buttress. After this portion of the procedure is completed laparoscopically, the meticulous reconstruction can be done through a remarkably small Pfannenstiel or lower midline incision. If a concealed umbilical stoma is planned, a U-shaped incision is made in the umbilicus.30 A superiorly based flap is raised in preparation for a concealed umbilical stoma, and the REVIEWS IN UROLOGY umbilical fascia incised sharply. Once the peritoneum is opened, a radially dilating 10- or 12-mm trocar is placed under direct vision. The remaining ports are positioned for the specific procedure planned. If a Malone antegrade continence enema is planned as a second stoma, the second port should be placed at the proposed right lower quadrant stoma site. Otherwise, the lower port is placed along the proposed line of eventual open incision. A third 2- or 3-mm port is placed in the midepigastrium (Figure 4). If the appendix is harvested, it can be divided laparoscopically with an ENDO-GIATM stapler (Autosuture, Norwalk, CT) or divided after bringing it through the open incision. Usually, little or no dissection is needed to mobilize small bowel or sigmoid colon. Once the bowel is mobilized and any other tissues needed are harvested, a 4- to 5-cm Pfannenstiel incision is made. This access is used for the bowel anastomosis, enterovesical anastomosis, creation of the stoma, and any bladder neck manipulation. Figure 4. For laparoscopic-assisted bladder reconstruction, 1 working port is placed along the expected incision. This allows incorporation of 1 port into the required small abdominal incision. An additional working port is placed in the midepigastrium. The camera is placed through the umbilical port. Reproduced with permission from Hedican et al.32 Laparoscopy in Pediatric Urology A laparoscopic grasper can be used through the retained umbilical trocar to draw the stoma to the umbilicus for maturing. The stomal segment is spatulated dorsally to allow the umbilical flap to conceal the inferiorly based stomal opening. Outcomes from laparoscopicassisted bladder reconstruction have been excellent. Chung and colleagues31 reported that 95% of patients were continent, with stomas that easily catheterize. Stomal stenosis occurred in 5.1%, and stomal revision was required in 7.7%. This compares favorably to results obtained by an open approach. The goal of laparoscopic-assisted reconstruction is to maximize the benefits of both laparoscopy and open techniques, in an effort to minimize patient morbidity while optimizing the outcome of meticulous reconstructive techniques. Laparoscopy allows access to the upper abdomen, which often requires a larger midline incision. By performing the more complex parts of reconstruction through a small open incision, the patient is spared the longer operative times that accompany purely laparoscopic reconstruction. In fact, the operative time required for laparoscopic-assisted reconstruction is no different from that for open reconstruction in similar procedures.31,32 Antireflux Surgery Surgical options for correcting vesicoureteral reflux include subureteric injections, open reimplantation, and laparoscopic reimplantation. Although open reimplantation has success rates of more than 95% and low morbidity, there is continued interest in finding less invasive methods of repair.33,34 Initial attempts at laparoscopic ureteral reimplantation used an extravesical approach. Early reports of this technique were met with some skepticism, but later reports have cited modifications to make it an appealing option in the hands of a skilled laparoscopist. One of the biggest challenges is intracorporeal and extracorporeal knot tying. Because of limited working space in a small pelvis, some guidelines have been suggested. Some investigators do not find the procedure appropriate for patients with megaureters requiring tapering or ureters with associated ureteroceles or for patients younger than 4 years.35 To perform an extravesical laparoscopic ureteral reimplantation, the bladder is first inspected with cystoscopy. A 3-Fr ureteral catheter might be placed at this time to help laparoscopic identification. Next, an infraumbilical incision is made to place a 3- or 5-mm trocar. In case an open conversion is required, a Pfannenstiel incision is outlined, and 3 trocars are placed along this line. One port is placed in the midline and 2 lateral ports along the midclavicular line. The ureter is found at the pelvic brim and followed to its bladder insertion. It is freed from adjacent connective tissue to elevate the ureter into view. The ureter is isolated with a large Babcock retractor or with umbilical tape. The detrusor tunnel is estimated after the bladder is distended. This should course slightly laterally to avoid kinking of the ureter. In most cases, a 3-mm tunnel is adequate to obtain a 5:1 ratio of length to width. Once the location of the tunnel is chosen, the detrusor muscle is divided full thickness while keeping the mucosa intact. The detrusor is then closed over the ureter with interrupted absorbable sutures, approximately 0.5 cm apart. There is no attempt to advance the ureter. An alternative approach is to perform an intravesical ureteral reimplantation. This was first described in an animal model.36 The procedure begins with cystoscopy and placement of ureteral stents. Then, two 5-mm balloon tip ports are placed off the midline and just above the symphysis pubis. The balloons are inflated with air and the external cuff pressed down to seal the port within the bladder. The ports are attached to continuous wall suction. The cystoscope is replaced with a resectoscope, which allows use of a Collins knife. The knife is used to dissect out both the intravesical component of the ureter and 2 to 3 cm of extravesical ureter. The continuous suction keeps the bladder decompressed and minimizes fluid extravasation. This dissection provides large enough mucosal flaps to cover the reimplantation. An absorbable suture is passed through a suprapubic port and used to secure the ureter in its new position. The intravesical approach avoids entry into the peritoneum and potential urinary retention due to injury to vesical nerves during extravesical dissection. Transvesical surgery is technically challenging because it requires laparoscopic mobilization of the ureter, creation of a submucosal tunnel, and suturing to secure the ureter into its new position, all within the space of an inflated bladder. Although this approach is technically feasible, its benefits have yet to be proven when measured against the outcomes of an open approach. Operative times have been reported as brief as 2.5 hours, with patient discharge in 24 hours.37 There are a few reports of robotically assisted laparoscopic antireflux surgery, with both extravesical and intravesical approaches. The techniques used are similar to those described above, but the robot might allow more precise manipulation of the tissue and faster operative times. Considering that, in our hands, ureteral reimplantation can be performed through a very small bikini VOL. 7 NO. 4 2005 REVIEWS IN UROLOGY 221 Laparoscopy in Pediatric Urology continued incision and requires only an overnight stay, it has been difficult to justify the laparoscopic techniques. That is not to say that the surgeons pursuing these techniques should not be pushing the envelope. As techniques improve, the threshold might be reached at which laparoscopic techniques become preferable to open ureteral reimplantation. a standard part of our specialty’s repertoire. Summary 3. As laparoscopy is applied more widely in pediatric urology, its potential benefits and drawbacks will become apparent. Laparoscopic orchidopexies and nephrectomies are commonly performed and have become widely accepted as alternatives to open surgery, if not the gold standard. The more technically demanding procedures, such as laparoscopic pyeloplasty, laparoscopic-assisted bladder reconstruction, and laparoscopic ureteral reimplantation tend to be performed at selected centers and have yet to achieve widespread acceptance. As experience increases, the enthusiasm and optimism of pediatric urologic laparoscopists will likely be justified by outcomes data, and minimally invasive surgery will become References 1. 2. 4. 5. 6. 7. 8. 9. 10. Kanemoto K, Hayashi Y, Kojima Y, et al. The management of nonpalpable testis with combined groin exploration and subsequent transinguinal laparoscopy. J Urol. 2002;167(2 Pt 1): 674-676. Docimo SG, Moore RG, Adams J, Kavoussi LR. Laparoscopic orchiopexy for the high palpable undescended testis: preliminary experience. J Urol. 1995;154:1513-1515. Cisek LJ, Peters CA, Atala A, et al. Current findings in diagnostic laparoscopic evaluation of the nonpalpable testis. J Urol. 1998;160(3 Pt 2): 1145-1149; discussion 1150. Peters CA. Complications in pediatric urological laparoscopy: results of a survey. J Urol. 1996; 155:1070-1073. Yerdel MA, Karayalcin K, Koyuncu A, et al. Direct trocar insertion versus Veress needle insertion in laparoscopic cholecystectomy. Am J Surg. 1999;177:247-249. Topuzlu Tekant G, Emir H, Eroglu E, et al. Experience with laparoscopy in nonpalpable testis. Eur J Pediatr Surg. 2001;11:177-181. Banieghbal B, Davies M. Laparoscopic evaluation of testicular mobility as a guide to management of intra-abdominal testes. World J Urol. 2003;20:343-345. Lindgren BW, Franco I, Blick S, et al. Laparoscopic Fowler-Stephens orchiopexy for the high abdominal testis. J Urol. 1999;162(3 Pt 2): 990-993; discussion 994. Baker LA, Docimo SG, Surer I, et al. A multiinstitutional analysis of laparoscopic orchidopexy. BJU Int. 2001;87:484-489. Docimo SG. The results of surgical therapy for cryptorchidism: a literature review and analysis. J Urol. 1995;154:1148-1152. 11. 12. 13. 14. 15. 16. 17. 18. 19. 20. 21. 22. 23. Gill IS, Kavoussi LR, Clayman RV, et al. Complications of laparoscopic nephrectomy in 185 patients: a multi-institutional review. J Urol. 1995;154:479-483. Keely FX, Tolley DA. A review of our first 100 cases of laparoscopic nephrectomy: defining risk factors for complications. Br J Urol. 1998;82: 615-618. Yao D, Poppas DP. A clinical series of laparoscopic nephrectomy, nephroureterectomy and heminephroureterectomy in the pediatric population. J Urol. 2000;163:1531-1535. Thomas MA, Rha KH, Ong AM, et al. Optical access trocar injuries in urological laparoscopic surgery. J Urol. 2003;170:61-63. El-Ghoneimi A, Farhat W, Bolduc S, et al. Retroperitoneal laparoscopic vs open partial nephroureterectomy in children. BJU Int. 2003; 91:532-535. El-Ghoneimi A, Valla JS, Steyaert H, Aigrain Y. Laparoscopic renal surgery via a retroperitoneal approach in children. J Urol. 1998;160(3 Pt 2): 1138-1141. Peters CA. Laparoscopic and robotic approach to genitourinary anomalies in children. Urol Clin North Am. 2004;31:595-605, xi. Troxel SA, Das S. Hand-assisted laparoscopy for multiple organ removal. J Endourol. 2004;18: 375-378. Janetschek G, Seibold J, Radmayr C, Bartsch G. Laparoscopic heminephroureterectomy in pediatric patients. J Urol. 1997;158:1928-1930. Gomez M, Gonzalez R. Laparoscopic nephrectomy in children: the transperitoneal vs. the retroperitoneal approach. Arch Esp Urol. 2003;56:401-413. Kavoussi LR, Peters CA. Laparoscopic pyeloplasty. J Urol. 1993;150:1891-1894. Schuessler WW, Grune MT, Tecuanhuey LV, Preminger GM. Laparoscopic dismembered pyeloplasty. J Urol. 1993;150:1795-1799. Docimo SG. Trans-mesenteric approach to left laparoscopic pyeloplasty. J Endourol. 2003;17: A321-A322. Main Points • A multi-institutional analysis of outcomes suggests an overall success rate for primary, 1-stage, and 2-stage laparoscopic orchidopexies of 92%, with an atrophy rate of 6.1%; these outcomes are more favorable than historical results for open procedures. • Most reports of pediatric laparoscopic nephrectomies have shown a low rate of complications; complications of primary interest are vascular and visceral injuries. Studies comparing transperitoneal and retroperitoneal approaches show similar rates for operative time, blood loss, and hospital stay. • Laparoscopic pyeloplasty in adults has shown a success rate greater than 95%, comparable to results with an open approach; reports in children have shown quicker return to normal activities than after an open procedure and comparable success. Although pediatric laparoscopic pyeloplasty series are limited, the numbers are increasing with favorable outcomes. • Outcomes from laparoscopic-assisted bladder reconstruction have been excellent. Investigators at one center reported that 95% of patients were continent, with stomas that easily catheterize; stomal stenosis occurred in 5.1%, and stomal revision was required in 7.7%. This compares favorably to results obtained by an open approach. • Because open ureteral reimplantation has relatively low morbidity for the patient, the utilization of laparoscopic ureteral reimplantation is still evolving. 222 VOL. 7 NO. 4 2005 REVIEWS IN UROLOGY Laparoscopy in Pediatric Urology 24. 25. 26. 27. 28. El-Ghoneimi A, Farhat W, Bolduc S, et al. Laparoscopic dismembered pyeloplasty by a retroperitoneal approach in children. BJU Int. 2003;92:104-108; discussion 108. Jarrett TW, Chan DY, Charambura TC, et al. Laparoscopic pyeloplasty: the first 100 cases. J Urol. 2002;167:1253-1256. Docimo SG, Moore RG, Adams J, Kavoussi LR. Laparoscopic bladder augmentation using stomach. Urology. 1995;46:565-569. Braren V, Bishop MR. Laparoscopic bladder autoaugmentation in children. Urol Clin North Am. 1998;25:533-540. Van Savage JG, Yepuri JN. Transverse retubularized sigmoidovesicostomy continent urinary diversion to the umbilicus. J Urol. 2001;166: 644-647. 29. Poppas DP, Uzzo RG, Britanisky RG, Mininberg DT. Laparoscopic laser assisted auto-augmentation of the pediatric neurogenic bladder: early experience with urodynamic followup. J Urol. 1996;155:1057-1060. 30. Glassman DT, Docimo SG. Concealed umbilical stoma: long-term evaluation of stomal stenosis. J Urol. 2001;166:1028-1030. 31. Chung SY, Meldrum K, Docimo SG. Laparoscopic assisted reconstructive surgery: a 7-year experience. J Urol. 2004;171:372-375. 32. Hedican SP, Schulam PG, Docimo SG. Laparoscopic assisted reconstructive surgery. J Urol. 1999;161:267-270. 33. Burbige KA. Ureteral reimplantation: a comparison of results with the cross-trigonal and Politano-Leadbetter techniques in 120 patients. 34. 35. 36. 37. J Urol. 1991;146:1352-1353. Lavine MA, Siddiq FM, Cahn DJ, et al. Vesicoureteral reflux after ureteroneocystostomy: indications for postoperative voiding cystography. Tech Urol. 2001;7:50-54. Lakshmanan Y, Fung LC. Laparoscopic extravesicular ureteral reimplantation for vesicoureteral reflux: recent technical advances. J Endourol. 2000;14:589-593; discussion 593-594. Lakshmanan Y, Mathews RI, Cadeddu JA, et al. Feasibility of total intravesical endoscopic surgery using mini-instruments in a porcine model. J Endourol. 1999;13:41-45. Gill IS, Ponsky LE, Desai M, et al. Laparoscopic cross-trigonal Cohen ureteroneocystostomy: novel technique. J Urol. 2001;166:1811-1814. 16th International Prostate Cancer Update January 18-22, 2006 Park Hyatt Beaver Creek Resort and Spa Beaver Creek, Colorado, USA PROGRAM CHAIRMAN E. David Crawford, MD University of Colorado Health and Sciences Center ■ Advances in science and state-of-the-art strategies for prostate cancer care Call for Abstracts ■ World-renowned faculty Deadline December 30, 2005 ■ Practical information for frontline prostate cancer clinicians to incorporate into their practices Who Should Attend This program is designed for urologists, radiation oncologists, medical oncologists, and specialists including registered nurses, residents, and fellows involved in the diagnosis, management, and treatment of prostate cancer. Submit a 500-word abstract to prostateabstracts@clinical options.com. Accepted submissions will be presented as posters at the poster reception. Benefits of Attending Jointly sponsored by Postgraduate Institute for Medicine and Clinical Care Options, LLC This activity has been approved for AMA PRA credit. Supported by educational grants provided by multiple commercial entities. Register Online Participants in previous years have cited the following as the most valuable benefits: ■ Cutting-edge information: High-quality sessions and speakers ■ Outstanding syllabus: Detailed, well organized, and an excellent resource clinicaloptions.com/ prostate2006 ■ Networking: Information exchange, including interaction with high-level faculty not found at other conferences Q uestions ■ Format: Balance of sessions with opportunity to interact with colleagues Call 866.618.5624 For more information and to register online: clinicaloptions.com/prostate2006 Enter or mention code MEDREV for a $100 discount on the registration fee. VOL. 7 NO. 4 2005 REVIEWS IN UROLOGY 223