Laparoendoscopic single-site surgery (LESS) for pediatric urological pathology has emerged as a viable alternative to standard laparoscopy. However, most single port devices are disposable, resulting in additional operative expense. In addition, availability of these devices is limited for small children. Our aim was to assess operative outcomes with different surgical approaches for LESS total and partial nephroureterectomy in pediatric patients, stratifying by weight.
Since March 2010 LESS total and partial nephroureterectomy were performed in 14 children. Indications for nephrectomy were non-functioning kidney due to vesico-ureteral reflux (n=6), giant cystic dysplasia (n=3) loss of renal function due to obstruction (n=1) and rudimentary kidney (n=1). Three patients underwent partial nephroureterectomy for non-functioning moieties in duplex systems, including one bilateral case. Children weighing below 10 kg underwent LESS nephroureterectomy through an umbilical incision using two 3 mm trocars and one 5 mm trocar in the so called “Manhattan-technique”. Patients above 10 kg were operated on using a metal multi-use single-site single port, with different diameters for instruments ranging from 3-12.5mm. The “Manhattan-technique” was used in all patients undergoing partial nephroureterectomy. Renal hilus dissection was performed using a variety of techniques, including vascular sealing devices, electrocautery and clip-ligation. All ureters were transected after ligation using a PDS-loop. Conventional straight laparoscopic instruments were used in all cases.
Mean age at operation was 27 months (0.75-128) and mean weight was 13.6 kg (3.1-67). Median operating time was 122 minutes (50-260). 11 children underwent LESS nephroureterectomy using two 3 mm trocars and one 5 mm trocar, and 3 patients were operated on with the multiuse device. All operations were completed in a standard laparoscopic transperitoneal technique without the use of additional trocars. There were no intra-operative complications. Postoperatively, one child who had undergone partial nephroureterectomy developed renal artery spasm, which resolved without sequelae. Another patient developed a postoperative urinoma at the site of partial nephroureterectomy of the upper pole, which resolved spontaneously within 5 days. Recovery was uneventful in the remaining 12 children.
LESS total and partial nephroureterectomy can be safely and efficiently performed in children, irrespective of age and weight. However, different surgical approaches have to be considered, as disposable single-site ports are not available for infants and small children. To decrease operative expenses, conventional multi-use trocars and a multi-use single-site port were used with conventional laparoscopic instruments. Technical problems included gas leakage due to failure of sealing, limitations of the range of movements due to the rigidity of the metal device, and tangling of instruments within the port. Despite the technical limitations, both techniques offer an alternative to contain procedural costs. However they will benefit from future development of instruments and trocars more suitable for small children.