Edited by: Miguel Alfedo Castellan, University of Miami, USA
Reviewed by: Nicholas Glenn Cost, Cincinnati Children’s Hospital Medical Center, USA; Pedro-José Lopez, Hospital Exequiel Gonzalez Cortes and Clinica Alemana, Chile
†Hong Mei and Teng Qi have contributed equally to this work.
This article was submitted to Pediatric Urology, a section of the journal Frontiers in Pediatrics.
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Congenital renal dysplasia is a consequence of abnormal nephrogenesis, and histologically characterized by dysplastic nephrons and collecting ducts (
To assess the clinical utility and efficiency of TMLN, with the institutional review board approval, we respectively reviewed 16 consecutive pediatric patients with dysplastic kidney, who underwent TMLN between January 2010 and December 2011 at the Department of Pediatric Surgery, Union Hospital of Tongji Medical College, China. Six patients suffered from urinary incontinence due to the ectopic ureter. The demographic characteristics of all patients were summarized in Table
Characteristic | Transumbilical multiport laparoscopic nephroureterectomy |
---|---|
No. of cases | 16 |
Age (months) | 33.8 (range: 7–62) |
Gender (M/F) | 5/11 |
Side (L/R) | 12/4 |
Urinary incontinence | 6 |
Ectopic ureter | 6 |
After the induction of general anesthesia, the patients were secured to the operating room table, and placed in the modified lateral decubitus position. A Foley urethral catheter was positioned to decompress the bladder. The oral-gastric tube was not routinely applied. Three ports were transumbilically placed at different positions and staggered in high, middle, and low dimensions (Figure
Pneumoperitoneum was created through the primary 5-mm port using carbon dioxide to a maximum pressure of 10–12 mmHg, and was maintained at 8 mmHg during surgery. A rigid, 5-mm, 30° telescope was introduced into the abdomen for an initial survey. The ureter was identified as it crossed the iliac vessels in the pelvis (Figure
The demographics, incision length, operative time, estimated blood loss, oral feeding time, length of stay, and perioperative complications for all patients were recorded and respectively analyzed. All patients were followed up for the symptoms, and the physical, urinary routine, ultrasonography, and/or renal scintigraphy examinations were performed at approximately 6, 12, 18, or 24 months postoperatively.
Of these cases, there were left-side in 12 patients, and right side in 4 patients. Their ages ranged from 7 to 62 months (mean: 33.8 months). TMLN was performed in all 16 cases, without additional ports or conversion to conventional laparoscopy or open surgery. The mean operative time was 108.4 min (range 90–125; Table
Characteristic | Transumbilical multiport laparoscopic nephroureterectomy |
---|---|
No. of cases | 16 |
Incision length (cm) | 1.3 |
Additional ports | 0 |
Operative time (min) | 108.4 ± 16.2 (range: 90–125) |
Oral feeding (h) | 36.3 ± 6.1 (32–48) |
Return to normal activities (days) | 2.8 ± 0.8 (2–4) |
Hospital stay (days) | 5.4 (range: 4–7) |
Complication (%) | |
Wound infection | 1 (6.3%) |
Subcutaneous emphysema | 1 (6.3%) |
Internal organ damage | 0 (0%) |
Hematuria | 0 (0%) |
Urinary infection | 0 (0%) |
The post-operative recovery was uneventful in all patients. No patients needed analgesic use after operation for the tolerable levels of pain. The mean length of hospital stay was 5.4 days (Table
All patients were followed up for 18–30 months (mean 22.6 months). No urinary incontinence occurred in all patients (Table
Characteristic | Transumbilical multiport laparoscopic nephroureterectomy |
---|---|
No. of cases | 16 |
Follow-up (months) | 22.6 (range: 18–30) |
Urinary incontinence | 0 |
Umbilical hernia | 0 |
Urinary infection | 0 |
Contralateral kidney function | |
Normal | 21 |
Abnormal | 0 |
In 1991, Clayman et al. first described the laparoscopic nephrectomy (
Despite the widespread acceptance of standard multiple-port laparoscopic surgery, there have been efforts to further reduce its invasiveness and access-related complications. In recent years, LESS was established as general term for all the new surgical procedures using only one skin incision for access of camera and instruments (
In our cases, we choose three separate skin incisions for trocar placement, with the aim to maximize spacing between the trocars within the limited umbilical wound. This may prevent the leakage of pneumoperitoneum, and the skin incisions are more cosmetic. The potential incision complications, such as incisional hernia and wound infection, are rare after this TMLN. In addition, we used conventional straight laparoscopic trocars and instruments to perform the procedures. Potential obstacles to single-port surgery include collision of instruments and hands, reduced intracorporeal work space, triangulation difficulties, and a steep learning curve. At the beginning, we indeed encountered difficulty in performing TMLN. Because the tight approximation of instrument placement restricts the surgeon’s hands to a narrow range of motion, it is technically changeling to accomplish the surgery in an efficient manner. The parallel alignment of these instruments also limits the triangulation, which is a founding principle of effective laparoscopic surgery. Moreover, in line placement of the telescope narrows the visual field, and forces the field of view to be limited by the movement of instruments. There are four main tricks to overcome these technical difficulties of TMLN. Firstly, three trocars are staggered at different heights to minimize collision at trocar heads. Secondly, two working trocars are lateral placed at 6 and 12 o’clock positions of the umbilical ring in order to maximize spacing between two working ports. These two trocars can be moderately and laterally placed along subcutaneous planes, resulting in adequate freedom of instrumental movement with reasonable triangulation and no torque on the trocars. The use of a 30° telescope provides better visualization for the manipulation of instruments. Thirdly, transabdominal hitch stitches can be introduced through the abdominal wall to lift the ureter or renal pelvis for easier dissection. The exact site of entry of the needle was determined under direct laparoscopic vision. Finally, the retrieval of laparoscopically resected specimens is difficult through the single working port. However, after conjoining the port sites, the specimen can be extracted easily. Once we ameliorate these techniques, we can accomplish the surgery in an efficient manner, which not only obviates the need for additional port site wounds, but also renders the operation virtually scarless.
Since the laparoscopic nephroureterectomy is a routine procedure in our center, we are prone to be familiar with the surgical steps of TMLN. Although there is still less range of motion, instrument crossing, and occasional instrument collision in TMLN, this procedure can be accomplished to achieve excellent results. Our intraoperative and post-operative data demonstrate that TMLN is a feasible and safe technique for renal dysplasia in pediatric patients. The average operative time in this series is <2 h, which compares favorably with that reported in standard laparoscopic nephroureterectomy (
Transumbilical multiport laparoscopic nephroureterectomy is a feasible and safe technique for pediatric patients. It can be performed with usual laparoscopic instruments. Once the technical limitations are overcome, the experienced laparoscopic surgeons can accomplish the TMLN in an efficient manner. Since our study is retrospective, the true value of TMLN in outcome analysis may be affected by the inner limitations in small number of cases. The benefits and limitations of TMLN need to be further confirmed by a prospective randomized study with a large number of cases and a long-term follow-up. We believe that TMLN procedure is an alternative technique of LESS procedure, which may be useful for pediatric urologists to choose the surgical approaches for the management of renal dysplasia in children.
The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.
This work was supported by the National Natural Science Foundation of China (No. 30600278, No. 30772359, No. 81071997, No. 81072073, No. 81272779, No. 81372667), Program for New Century Excellent Talents in University (NCET-06-0641), Scientific Research Foundation for the Returned Overseas Chinese Scholars (2008-889), and Fundamental Research Funds for the Central Universities (2010JC025, 2012QN224).