Alessandro Settimi Ciro Esposito “Federico II” University, Naples Italy Division of Pediatric Surgery Chief: Prof Alessandro Settimi Minimally Invasive Surgery In Pediatric Urology

MIS is an alternative approach to OPEN SURGERY

Instruments

Laparoscopic Primary Pullthrough for Hirschsprung’s disease Aspetto Estetico LAPAROTOMIA LAPAROSCOPIA

Urinary tract pathologies - VUR - UPJO - MKDK - Non functioning Kidney - Duplex Kidney - Stones - Urachal cysts - Ureter pathology

Duplex Kidney

Partial - Nephrectomy Non-functioning upper or lower pole secondary to complicated duplex anomalies of the kidney The usual pathology of the upper pole is obstruction associated with a ureterocele or incontinence secondary to an ectopic ureter The usual pathology in the lower pole is reflux Indication

Partial nephrectomy is technically more demanding than total nephrectomy Currently, this procedure is performed using a retroperitoneal or transperitoneal approach. Partial Nephrectomy Lee RS et al: Pediatric retroperitoneal lap… J Urol 174: 702, 2005

LAPAROSCOPIC PARTIAL NEPHRECTOMY (LPN)

Patient’s Position Position for a right Nephrectomy LATERAL POSITION A ballast is placed under the patient

Patient’s Position #2

Team

Trocars 1: 10mm 2: 5mm 3: 5mm 4: 5mm 4 5mm 4

Step # 1 Stent positioning Incision of the lateral peritoneal fold

STEP # 2 Colon

STEP # 3 Ureteral section

STEP # 4 Kidney

STEP # 5 vessels u.p.

STEP # 6 Hemi-nephrect u.p.

STEP # 7 Specimen removal

LPN personal Results Operative time: 90 min (70 to 120) Lenght of stay: 3-4 days Conversions: 0

Laparoscopic transposition of lower pole crossing vessels in extrinsic uretero-pelvic junction (UPJO) obstruction in children

Background # 2 A recent study demonstrated that 58% of older children with symptomatic PUJO had lower pole crossing vessels [ The traditional management for lower pole vessels causing PUJO has been dismembered pyeloplasty The Hellstrom procedure, in which crossing polar vessels are relocated, has been an option in adult urological practice

Clinical findings Indication: abdominal pain presenting as Dietl’s crisis, UTI and rarely haematuria Median age of presentation > 6 years Absence of pre-natally detected hydronephrosis

Pre-operative work-up Renal ultrasonography Doppler ultrasound Scintigraphy MRI

Technique # 1 At laparoscopy the presence of a lower pole vessel is confirmed in the absence of a narrow PUJ The PUJ and the pelvis are adequately mobilised achieving easy displacement of vessels

Technique # 2 The ‘ shoe-shine ’ manoeuvre of the mobilised anterior pelvis behind the lower pole vessels confirms adequate availability of the pelvis to perform a loose wrap around the vessels

Technique # 3 Two or three interrupted sutures may be necessary to achieve an adequate tunnel within the anterior pelvic wall

Trocars 1: 10mm 2: 5mm 3: 5mm 4 4

STEP # 1 Dissection

STEP # 2 pelvis

STEP # 3 wrap

Classic UPJO

Patient’s Position #2

Trocars 1: 10mm 2: 5mm 3: 5mm 4 4

Lap Pyeloplasty

Urachal Anomalies In Pediatric Patients

Background Urachus is a 3-layered canal that connects the allantois to the fetal bladder. Descent of the bladder in month 5 of development stretches the urachus, causing its lumen to obliterate and become the median umbilical ligament. Occasionally this process may be incomplete and an epithelialized urachal canal may persist into adulthood.

Background # 2 This leaves the potential for various urachal anomalies, including cysts, sinus tracts, diverticula and malignancies 1) vesicourachal diverticulum 2) urachal cyst 3) Umbilical-urachus sinus

Indication Children with urachal anomalies, in about % of patients have symptoms (umbilical drainage, hematuria, UTI, abdominal pain), In the other % of patients the urachal anomalies are diagnosed incidentally during abdominal surgery performed for another indication

Technique # 1

Technique # 2

Technique # 3

Technique # 4

Technique # 5

LEVUR Laparoscopic Lich-Gregoir procedure In patients with VUR

VUR Techniques STING COHEN % Success Rate % Day Surgery Hospitalisation 6-10 days No Pain Yes Ureteral Cath after No

LEVUR Laparoscopic Lich-Gregoir procedure

Trocars Position Optic 5mm 30° 3-mm trocars

LEVUR # 1 Ureter Isolation

LEVUR # 2 Ureteral Dissection

LEVUR # 3 Fix and prepare the bladder

LEVUR # 4 Ureter reimplantation

LEVUR # 5 Final Check

No ScarsPfanenstiell Incision3 small scars Day SurgeryHospitalisation 5-10 dHospitalisation 24-36h No Pain post-op discompfort 8-15 Days No pain 1st Inj : 75-85% 2nd inj : 90-95% % Cistoscopy ?? 95-96% Ureters in the same axis RESULTS # 2

Difficult procedure to perform Delicate and fine dissection It’s fundamental to know the details of the technique Day surgery, excellent post-operative period No pain, no drugs, no catheters Comparable results with open Cohen Conclusions SURGEON ++ PATIENT

OPEN COHEN 5 Post Op day LEVUR 1 Post Op day

LAPAROSCOPIC Nephrectomy in Pediatric Patients

Nephrectomy Indication  Non-functioning kidney secondary to VUR  Non-functioning kidney secondary to UPJO with an ureterostomy  Pelvic Kidney  Previous renal surgery  Infections

Trocars 1: 10mm 2: 5mm 3: 5mm

Step # 2 Isolate Kidney and ureter Vessels clipped and sectioned Ureter clipped and sectioned Remove the Kidney

Step # 1 ureter

Step # 2 vessels

Advanatages of MIS in Pediatric Urology Improve precision thanks to magnified view Less Pain Less Drugs Shorter Hospital Stay Better Cosmesis Same good long term Results

CONCLUSIONS In the 21° century it is unacceptable to perform any surgical procedure on a child by the open route if it can be safely and easily be carried out through minimally invasive surgery Gordon Mc Kinlay