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, laparoscopic-assisted 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.
Keywords: Laparoscopy, Pediatric, Orchidopexy, Nephrectomy, Pyeloplasty
1-Pediatric 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 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.
2-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.
3-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.
4- 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
5- 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
6-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 Fowler-Stephens orchidopexy is recommended.6
7-When orchidopexy is performed laparoscopically, 3 ports are placed: 1 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.