Minimally invasive urologic surgery in children: an overview of what can be done.

PURPOSE: Laparoscopy has emerged as a feasible and effective alternative for abdominal pathologies in children. Urological minimally invasive surgery is now commonly used for basic operations in most centres and is just beginning to expand its use in more complex operations in several selected centres around the world. We present the current state of the art of minimally invasive surgery in children. MATERIAL AND METHODS: We first reviewed all the urological pathologies treated with minimally invasive surgery in our institution. Secondly we reviewed the literature in order to highlight and discuss certain relevant articles and compare them with our own experience. RESULTS: Since beginning to use minimally invasive surgery at our institution we have operated more than 550 cases with urological pathologies. We used three approaches: the transperitoneal, the retroperitoneal and the transvesical approach. Our preferred indications for each approach are discussed. DISCUSSION: Non palpable testis, varicocele surgery, nephrectomy and adrenalectomy are, in our opinion, established minimally invasive procedures. Hemi-nephrectomy, pyeloplasty and Cohen antireflux surgery are probably excellent indications when minimally invasive surgery is carried out by expert hands. Stone management should not be forgotten in cases of contraindication or failure of ESWL. Even the most complex urological operations may be safely carried out using a minimally invasive approach, although most of the cases described are case reports. CONCLUSION: More papers are published on ablative or reconstructive urological minimally invasive surgery. Transperitoneal and retroperitoneal approaches are used with the same results. Transvesicoscopic surgery should rapidly grow to become a standard approach for Cohen reimplantation. It is anticipated that technical progress will provide the opportunity for more paediatric urologists to develop a minimally invasive approach.

Current indications for laparoscopy and retroperitoneoscopy in pediatric urology.

Laparoscopy has raised great interest in the past few years in the field of pediatric urology. It has evolved from a simple diagnostic maneuver to complex operative procedures. The aim of this study was to review urologic laparoscopy literature and provide a critical review of this field to establish current indications for videosurgery in pediatric urology. In general, from an anatomic point of view, retroperitoneoscopy seems to be more suitable than the transperitoneal laparoscopic approach for reaching the upper urinary tract. It also is less invasive and complies with the criteria for open renal surgery. With respect to current indications for videosurgery in pediatric urology, the authors have identified several well-established clinical procedures, although no large series have been published for any of the procedures, except for the treatment of varicocele, nonpalpable testis, and nephrectomy. In conclusion, the data reviewed suggest that videosurgery is a safe and feasible technique in pediatric urology if performed by expert surgeons, and that it certainly will develop further in the next few years.

Long-term outcome of laparoscopic Nissen and Toupet fundoplication in normal and neurologically impaired children.

BACKGROUND: Laparoscopic fundoplication is a commonly performed procedure in children. This report describes the incidence of long-term recurrence and complications after laparoscopic Nissen or Toupet fundoplication in neurologically impaired and normal children. METHODS: Fifty-three children operated on before 1999 were reviewed. All children were evaluated clinically and with a barium meal study thereafter. Symptomatic children and those with abnormal barium meal underwent 24 h pH monitoring. RESULTS: A total of 45 patients were included in the study. The mean follow-up was 4.5 years. All, except one asymptomatic child that declined, had a barium meal. Four were abnormal (2 parahiatal hernias and 2 slight episodes of reflux). Four patients had symptoms related to the operation and 2 to clinical recurrence. Only 1 asymptomatic child with slight reflux at barium meal revealed abnormal 24 h pH monitoring. Finally, 6.6% patients were found to have late recurrence (2 clinical and 1 pHmetry). There was an obvious increase in children's weight, especially in neurologically impaired patients. CONCLUSION: Laparoscopic antireflux surgery is of value in children with gastroesophageal reflux disease. The long-term results are comparable with open surgery, and there was no difference in term of wrap failure between neurologically impaired and normal children.

Hepaticoportoappendicostomy.

In one case of extrabiliary atresia, reconstruction of the biliary tract was performed by using the appendix. The child, who was 2 years old, is doing well without ascending cholangitis. This operation seems simple and satisfying because it seems to be more anatomic and more physiologic than the standard Kasai operation. Its efficacy in a large number of cases remains to be proven.

Laparoscopic appendectomy in children: report of 1,379 cases.

The authors present a retrospective analysis of 1,379 pediatric laparoscopic appendectomies. The patients' average age was 10 years (range, 2 to 16 years). On gross examination, 90% of the appendixes appeared inflamed; on microscopic examination, 93% had evidence of acute appendicitis. The incidence of appendiceal peritonitis was 16%. Nonappendiceal lesions were identified in 10% of patients. The incidence of minor intraoperative events was 2.1%, and the postoperative complication rate was 1.5%; 0.7% of patients required a subsequent laparotomy or additional laparoscopic procedure. There were no deaths. The children were discharged after a 2-day (average) hospitalization and returned to unrestricted activities 1 week after surgery. The advantages of laparoscopic appendectomy are its easy and rapid localization of the appendix, the ability to explore the entire abdominal cavity, the ability to lavage completely the contaminated peritoneal cavity, and a reduction in the incidence of intraperitoneal abscesses and postoperative adhesions. Laparoscopic appendectomy offers reduced parietal scarring, a shorter hospital stay, and an earlier return to normal activities, even in cases of complicated acute appendicitis. Our experience confirms that laparoscopic appendectomy is safe and effective in children.

Is the appendix graft suitable for routine biliary surgery in children?

BACKGROUND/PURPOSE: The appendix graft (AG) is used widely for urinary tract replacement in children. Biliary tract replacement is less common. The purpose of this retrospective multicentric study was to evaluate the safety of appendix grafting for biliary reconstruction. METHODS: The files of 33 patients treated at 7 European pediatric centers were reviewed. Indications included choledochal cyst (CC) in 5 cases, biliary trauma (BT) in 1, and biliary atresia (BA) in 27. In CC and BT patients, the graft was inserted isoperistaltically between the proximal biliary duct and second duodenum. In all but one of the BA patients, the graft was placed antiperistaltically by patching its cecal end onto the porta hepatis. RESULTS: Postoperatively, all CC and BT patients initially became asymptomatic but developed laboratory evidence of anicteric cholestasis within 1 year. The most common manifestation was increased gamma-glutamyl-transpeptidase level (GGT), whereas histologic findings showed liver damage (mainly fibrosis). Reoperation has been carried out in 4 CC and 1 BT patients within a mean period of 19 months after appendix grafting. The graft procedure was converted to hepaticojejunostomy (HJ) in 4 and to choledocoduodenostomy in 1. Surgical exploration showed kinking in 1 patient and stenosis in 1. In the remaining 3 cases, there was no discernible cause of cholestasis, and appendix histology findings were normal. In all 5 reoperated patients, liver function findings returned to normal within 1 month. Reoperation is scheduled for the remaining CC patient who currently requires ursodesoxycholic medication to maintain normal liver function and presents histologic evidence of "de novo" sclerosing cholangitis. Results of appendix grafting also were poor in the 27 BA patients. Procedure-related perioperative complications occurred in 4 (15%) including 1 early death from graft necrosis. Another early death resulted from intestinal hemorrhage. Jaundice cleared in only 8 (28%). CONCLUSIONS: The findings of this study suggest that the AG is unsuitable for routine biliary repair in children. It should be used only as a salvage technique when conventional HJ repair is contraindicated. Because of the high risk of graft dysfunction, we recommend screening tests to detect biochemical or histologic cholestasis in any patient previously treated with appendix grafting.

Diaphragmatic duodenal atresia: laparoscopic repair.

Stenosis due to a diaphragm is a type of intrinsic duodenal obstruction in newborns and even in childhood, when obstruction is partial. We present a case of a 13-month-old girl with diaphragmatic stenosis associated with a dilated first and second duodenum. Surgical management consisted of a partial excision of the diaphragm after vertical incision of the anterior part of the second duodenum followed by a transverse suture. This diamond-shaped anastomosis was successfully carried out laparoscopically. No tapering of the duodenum was performed as some authors suggest in cases of megaduodenum. The rapid resumption of peristalsis and fewer adherences than expected after such a minimally invasive approach could make a more invasive procedure unnecessary. Only long-term follow-up and greater experience will show which procedure is most suitable.

Meckel's diverticulum and laparoscopy of children. What's new?

Laparoscopy has not changed the diagnostic approach in Meckel's diverticulum (MD). Preoperative echography and scintigraphy are still indicated in case of symptomatic diverticulum. During each submesocolic laparoscopy we must meticulously look for Meckel's diverticulum. There are two surgical procedures for MD resection: 1. Short intestinal resection after exteriorization (celio-assisted surgery) is advocated in young patients or in complicated MD. 2. Laparoscopic resection by the Endo GIA stapler is advocated in older patients and latent MD with a narrow base.

Single-stage correction of posterior hypospadias (178 cases). Comparison of three techniques: free skin graft, free bladder mucosal graft, transverse pedicle preputial graft.

Three techniques have been developed for single-stage repair of posterior hypospadias: free skin grafts, free bladder mucosal grafts, and pedicle preputial grafts. This multicenter retrospective study of 178 children who underwent surgery for posterior hypospadias was designed to compare the results achieved with these procedures. Free skin grafts (15 cases) resulted in the most frequent complications, and in particular the most severe strictures; in our opinion this technique should be abandoned. Pedicle preputial grafts (133 cases) gave the greatest number of successes from the outset, and should be preferred whenever the dimensions of the prepuce are sufficient for urethroplasty. Results with bladder mucosal grafts (30 cases) were not as good as with preputial grafts, but this technique remains the only solution when the meatus is in a very posterior position, and for children who have already undergone multiple operations.

Retroperitoneoscopic approach to the adrenal glands and retroperitoneal tumours in children: where do we stand?

Choosing the best way to approach adrenal gland and retroperitoneal tumours is still difficult. We reviewed our first 10 cases operated on by retroperitoneoscopy and compared this approach with other possible ways described in the literature. There were 2 intraoperative complications: 1 opening of the diaphragm and 1 bleeding. Tumour resection was always complete. There was no conversion. There were no postoperative complications. The retroperitoneoscopic approach for adrenalectomy and retroperitoneal tumour resection is increasingly being used. In children, operation is quite fast, without much blood loss and with spectacular postoperative recovery results. Even for the right side we advocate this approach, due to the particular anatomy (small tumour size, less fat, thinner muscle layers) in this age group. Trained surgeons are, of course, mandatory.

Laparoscopic appendectomy in children: sense or nonsense?

The authors present a retrospective analysis of their first 1.500 paediatric laparoscopic appendectomies. Three types of techniques (OUT, MIXED, IN) are described. The average age of the patients was 8 years (range: 2 to 16 years). In case of acute appendicitis the postoperative complication rate was 0.6%. In case of peritonitis the postoperative complication rate raised to 13.3%. Conversion rate was 3.3%. There were no death. Mean hospital stay was 1.8 days for acute appendicitis and 6.5 days for peritonitis. Laparoscopic appendectomy in children has an unquestionable diagnostic interest, decreases the parietal complications and has a better cosmetic result in case of peritonitis or ectopic appendicitis. Benefits are highest in case of peritonitis by decreasing postoperative pain and length of hospital stay. The teaching value for learning laparoscopic surgeons is obvious. Increase of intraperitoneal residual abscesses, as well as increasing cost, remain controversial. This series is a plea for laparoscopic appendectomy in children.

[Solid and pseudopapillary tumor of the pancreas: immunohistochemical and ultrastructural study of 2 pediatric cases]. / Tumeur solide et pseudo-papillaire du pancréas : étude immunohistochimique et ultrastructurale de 2 observations pédiatriques.

We report 2 cases of solid and pseudopapillary tumors of the pancreas occurring in female children. Lesions were made of uniform small cells arranged in solid areas associated with pseudopapillary and cystic patterns. Immunohistochemistry study was positive for neuron-specific enolase, alpha-1 anti-trypsin and vimentin. Ultrastructural study showed an abundant cytoplasm, rich in mitochondria, containing a lot of granules of variable sizes, often disintegrated, and some lipid droplets. The differential diagnosis of this lesion included endocrine tumor, pancreatoblastoma and acinar cell carcinoma. It is a rare tumor of the pancreas with a favorable prognosis after complete resection.

[Adnexal torsion in children: plea for early laparoscopic diagnosis and treatment]. / Torsion d'annexe à l'âge pédiatrique: plaidoyer pour un diagnostic et un traitement plus rapides par laparoscopie.

BACKGROUND: Experience with adnexa torsion in children, a rare but potentially severe pathology, is still disappointing despite constant radiological progress. PATIENTS AND METHODS: The files of 19 patients with adnexial torsion treated between 1985 and 1995 were retrospectively reviewed and compared to those reported. RESULTS: Eight adnexectomies, six oophorectomies, five detorsions with cystectomy and one salpingectomy were performed. There were only five salvaged adnexa in this series. Three tumors were found; all other cases, except three, were torsions induced by voluminous functional cysts. DISCUSSION AND CONCLUSION: Clinical context (sudden right pelvic pain without fever) seems important to note. Sonographic examination is first necessary, but its results are not accurate enough to confirm the torsion. Endo-rectal ultrasonography should become the best diagnostic method in cases of complicated ovaries. In order to increase the percentage of salvaged adnexa, the authors recommend a laparoscopic approach in emergency when clinical examination was doubtful.

[Conservative treatment of traumatic rupture of the biliary ducts: a case report]. / Traitement conservateur des ruptures traumatiques des voies biliaires: à propos d'un cas.

The diagnosis of a biliary duct transection after blunt trauma is difficult in children. Surgery is often performed late and therefore complicated. We present a case of mini-invasive approach for biliary duct transection in a 12-year-old child and review the literature. Transhepatic cholangiography is at the moment the most used technique to make the diagnosis but necessitates general anaesthesia. Stent placement is possible by the way. Endoscopic retrograde cholangiogram (ERCP) has been proposed even in children. Stent placement may be easier by this technique. For the diagnosis, Technetium 99m dimethylminodiacetic acid (HIDA) scanning seems interesting in terms of both sensitivity and specificity. Another promising diagnostic technique is MRI with 3D reconstruction.

-Neonatal Kasabach-Merritt syndrome healed by complete surgical excision of the angioma-. / Syndrome de Kasabach-Merritt néonatal guéri par exérèse chirurgicale complète de l'angiome.

BACKGROUND: Kasabach-Merritt syndrome is an infrequent combination of a giant hemangioma and severe thrombocytopenia. This syndrome may be life-threatening. There are various but no definitive methods of treatment. We describe here a neonatal case cured by total excision of the tumor. CASE REPORT: A boy was admitted at birth with a giant hemangioma of the back with thrombocytopenia. Tumor compression, corticosteroids, acetylsalicylic acid and ticlopidine were ineffective. Total surgical excision was performed on day 51, resulting in complete recovery. CONCLUSION: Total surgical excision of a localized hemangioma in a non-functional area is probably the most appropriate and justified treatment for the Kasabach-Merritt syndrome.

[Lethargic form of acute intestinal intussusception in an infant]. / Forme léthargique d'invagination intestinale aiguë du nourrisson.

BACKGROUND: Intussusception encephalopathy, a misleading form in which neurological symptoms are obvious, is classic but rarely described. CASE REPORT: A 21 month-old infant was admitted because he had suffered from fluctuating consciousness and apathy for a few hours. Vomiting occurred soon afterwards. Search for dehydration, meningitis, encephalitis, poisoning... was negative; the abdomen was tender leading to ultrasonography that showed a sausage-shaped tumor. The ileocolic intussusception was successfully reduced with a gas enema. CONCLUSION: A striking degree of lethargy associated with vomiting may overshadow to a considerable extent the classical intestinal manifestations. A possible endogenous opioid poisoning by massive secretion of endorphins during pain's paroxysm is one of the hypotheses explaining this type of presentation.

[Two rare case reports of ureteral triplication]. / A propos de deux cas rares de triplication urétérale.

Triplication of the upper urinary tract is rare. It is classified according to its extent and four types have been documented. Since the first description of ureteral triplication by Wrany only about a hundred cases have been reported in the literature. Paediatric cases are very few and female patients seem more concerned. The embryological event resulting in ureteral triplication derives from multiple ureteral buds arising from the Wolffian duct with fissuring of one or more of them. We report on two cases of ureteral triplication. The first one associated with an extravesical ectopic ureter and a dysplasic kidney. Diagnosis was particularly difficult and treatment consisted of total nephrectomy. The second case was associated with an upper pole hydronephrosis and a partial nephrectomy was realized.

[Mini-invasive surgery of the retroperitoneal space in children]. / Chirurgie mini-invasive de l'espace rétropéritonéal chez l'enfant.

UNLABELLED: Although laparoscopic surgery now represents today an essential surgical technique, its use remains limited in urology and especially in pediatric urology for many reasons, main because of the lack of indications. After a large experience acquired in abdominal laparoscopic surgery, and because we were convinced of the advantages offered by this new mini-invasive approach, we have tried to develop it for the retroperitoneal space. METHODS: Over a five-year period we performed 88 retroperitoneal procedures in children:--50 nephrectomies (44 total, 10 partial) for the following indications: 15 polycystic dysplastic kidney, 13 kidney destroyed by reflux, 18 by obstruction, hypertensive uropathy 3, pyonephrosis 1.--5 renal cystectomies, 3 pyelolithotomies, 2 pyeloureteral obstructions, 2 adrenalectomies, 1 retrocaval ureter, 25 varicoceles. The age range was 2 months to 16 years (mean: 3.7 years, 25 children under 1 year). The patients were placed in the lateral debubitus. The retroperitoneal space was created by dissection under direct vision, then insufflation was performed directly in the retroperitoneal space without balloon. Three or four ports were used except for varicocelectomy which was performed with only one port and an operating channel telescope. RESULTS: Follow-up range was 6 months to 5 years. The mean operating time was 96 minutes (35 to 210 min.). Average postoperative stay was 2 days. Conversion was needed in 7 cases (8%). Operative incidents consisted of one duodenal perforation, one ureteral burn, 21 peritoneal perforations (24%). There were 5 postoperative complications (2 urinomas after partial nephrectomy, 1 hydrocele, 1 varicocele recurrence, 1 recurrent stones) not related to the technique. 3 cases needed reoperation (ureteral injury, varicocele recurrence, recurrence of cystine stones) with good result. CONCLUSION: Like other laparoscopic techniques, retroperitoneoscopy requires a training: it remains delicate in children because of the reduced working space and the fragility of the peritoneum. However the advantages seem sufficiently obvious for us to recommend and promote this procedure.

[Benign testicular tumors in children. Value of simple tumorectomy]. / Tumeurs bénignes du testis chez l'enfant. Intérêt de la tumorectomie simple.

From 1984 to 1999, the authors observed 18 intratesticular tumours, 13 of which corresponded to benign lesions. The objective of this study is to define preoperative and intraoperative criteria of benign lesions in order to allow conservative management (simple excision or enucleation) and to analyse the results of this treatment. The 13 boys of this series were between the ages of 5 months and 14 years (mean: 7.1 years). The lesion presented as scrotal swelling in 12 cases and gynaecomastia in 1 case. Tumour markers (alphafoetoprotein, beta HCG) were at the limit of normal for age. Ultrasonography was performed in every case. In each case, treatment consisted of primary exposure of the pediclc with clamping then exteriorization and macroscopic examination of the lesion. Frozen section examination was performed in 11 cases. Treatment consisted of 9 enucleations and 4 orchidectomies. The final histology concluded on epidermoid cyst or simplified teratoma with exclusively ectodermal development in 4 cases, multi-differentiated teratoma in 2 cases, sex cord tumour in 2 cases, simple cyst in 2 cases, rete testis dysplasia in 1 case, cavernous haemangioma in 1 case, and vestigial cyst in 1 case. There was no discordance between the final histological examination and the frozen section examination. The mean follow-up is 4.4 years. No secondary atrophy and no local or distant recurrence was observed in the 9 cases of enucleation. In conclusion, testicular tumours are often benign in children. Selection based on a body of clinical, laboratory, radiological and frozen section histological evidence should allow carcinologically safe conservative surgery with an aesthetic, psychological and functional benefit for the child.

[Urinary lithotripsy in children. Multicenter study of the Pediatric Urology Study Group]. / Lithotritie urinaire de l'enfant. Etude multicentrique du Groupe d'Etudes en Urologie Pédiatrique (GEUP).

The authors present the results of a survey conducted among French paediatric urologists belonging to the Groupe d'Etudes en Urologie Pédiatrique (GEUP) (Paediatric Urology Study Group). This study, based on 122 cases observed in 13 centres, is not exhaustive, but is nevertheless statistically significant. The preoperative assessment confirms the usual findings of urinary stones in children: pyelonephritis, haematuria and abdominal pain, the usual presenting complaint, concomitant malformative uropathy (10% of cases) and a predominance of calcium stones. More than 200 stones were treated, larger than 10 millimeters in diameter in one-third of cases. Renal stones, mainly caliceal (more than 50%), included 11 staghorn calculi. This study also included 22 ureteric stones, mainly in the pelvic ureter, and 2 bladder stones. Lithotripsy was ultrasound-guided in 2/3 of cases and required general anaesthesia in about 3/4 of cases. Ureteric catheterization was required in 19 infants preoperatively, but in only 2 infants (stein strasse) postoperatively. One or two lithotripsy sessions were sufficient in most cases, but 4 sessions were necessary in 5 patients, to the same kidney in 1 case. The mean hospital stay was 2 to 3 days, but the procedure was performed on an outpatient basis in 15 cases. The immediate postoperative course was uneventful and asymptomatic. This survey revealed about 10% of complete failures, corresponding to solitary caliceal stones in 2/3 of cases; 29 partial failures were essentially due to lower caliceal stones and staghorn calculi; 84 successes (stone-free), mainly pelvic or simple caliceal stones. Scintigraphy did not reveal any immediate postoperative impairment of renal function. This study reported a success rate of about 70%, regardless of the type of apparatus used. Assessment of the results of ESWL requires sufficient follow-up both concerning the outcome of fragmented stones and evaluation of possible functional repercussions. This survey defines the main indications: although ESWL can be applied to most stones, some stones constitute poor indications (cystine stones, stenotic malformative uropathy) or dubious indications: small lower caliceal stones, densely calcified staghorn calculi in older children. This study confirmed the efficacy and low morbidity of ESWL in children. A prospective study needs to be conducted according to a rigorous protocol in order to refine the technique and indications while reducing the possible long-term risks.