The advantage of laparoscopic pelvic dissection of pediatric pelvic rhabdomyosarcoma. Riquelme Mario, MD1; Garza Ulises, MD2; Rodriguez Alejandro, MD3; Aranda Arturo, MD4 1,4 Pediatric Surgery Hospital San José- Tec de Monterrey 2,3 General Surgery Hospital San José- Tec de Monterrey Introduction: While rhabdomyosarcoma is the most common soft tissue sarcoma of childhood, it rarely affects the genitourinary system (1). One series spanning 33 years identified only 22 such cases (2). Staging is based on tumor site, degree of post-surgical residual disease, and regional lymph node involvement (1). Treatment often includes surgery, chemotherapy and radiotherapy, although the ideal timing, extent and intensity of these interventions has not been established (3). Besides an optimal visualization, the minimal invasion approach has shown to provide the benefit of improved functional result in terms of potency in male patients (4). Laparoscopic management of benign tumors in the pediatric population has been widely reported, however there are few cases describing this approach for resection of malignancy, nerve sparing and erections (5). Materials and Methods: From 2006 to 2010, 3 patients with pelvic rhabdomyosarcomas were operated using laparoscopy. Two females, both 3 years old with bladder rhabdomyosarcoma and a 6 yo male with prostatic rhabdomyosarcoma that was invading the bladder floor (Fig 1, Fig 2, Fig.4A, 4B). Both females were treated by total laparoscopic cystectomy. The 6yo male was treated with neo-adjuvant chemotherapy and conformational XRT. After this treatment (Fig 3), CT scan suggested recurrence and he re-started chemotherapy and because of the bladder floor involvement, we decided to scheduled for total laparoscopic cystoprostatectomy. In all of the three cases, an open mitrofanoff continent urinary diversion was performed. Surgical technique: The patient was placed in lithotomy. He was given general anesthesia and then prepped and draped in the usual standard sterile fashion. A cistoscopy was performed preoperatively; tumoral activity in the prostatic urethra and bladder neck was confirmed by direct visualization (Fig 4). On the three cases, a total of four trocars were used, one in the umbilicus, one suprapubic and one in each lower quadrant. Dissection of the bladder was initiated using the Harmonic scalpel exposing the Retzius space (Fig 5). Details of the male case: both ureters were identified and dissected from the peritoneal fold (Fig 6, Fig 7). Vascular control of the bladder was then performed, the endopelvic fascia was then entered bilaterally to expose the puboprostatic ligaments. The rectourethralis muscles were then divided and dissection of the prostate off the rectum proceeded without difficulty, the pedicles were controlled and divided exposing the posterior bladder neck and Denonvillier´s fascia(Fig 9), the seminal vesicles were identified and removed (Fig 8). The vas deferens was cut bilaterally. Once the bladder and prostate were completely liberated by dividing of the puboprostatic ligaments both ureters were divided, with a 3mm proximal specimen sent to trans operative biopsy to determine margin status. The urethra was then divided sharply (Fig 10). The specimen was extracted through a midline incision (Fig 11). A final urethrocystoscopy is done, showing no evidence of tumor. An open mitrofanoff continent urinary diversion was performed. Results: The three patients had a successful recovery. An umbilical catheter was placed and used for divert the urine from the pouch. Both females had uneventful recoveries, discharged on postoperative day 6. The male had a wound infection as a minor complication, tolerated PO on 3rd day, had spontaneous erections on the 8th, and discharged at the 10th day. Conclusion: Laparoscopic dissection of pelvic structures provides the same benefits on the pediatric population as reported in adults. The magnification of anatomical structures during careful laparoscopic dissection provides optimal nerve sparing conditions. This report demonstrates the un-eventful recoveries and spontaneous erections. We experienced no laparoscopy-associated complications, and all 3 patients had successfully recoveries. The advantages, safety and feasibility of the minimally invasive approach for the resection of malignant genitourinary tumors should be clearly established in the near future as further reports become available. Bibliography: 1.Castellino SM, McLean TW. Pediatric genitourinary tumors. Curr Opin Oncol 2007;19: 248-253 2.Filipas D, Fisch M, Stein R, Gutjahr R, Hohenfellner R, Thüroff JW. Rhabdomyosarcoma of the bladder, prostate or vagina:the role of surgery. BJU Int 2004; 93: 125-129 3.Wu HY, Snyder HM, Womer RB. Genitourinary rhabdomyosarcoma: Which treatment, how much, and when? J Pediatr Urol 2009; 5: 501-506 4. Rocco B, et al. Robotic vs open prostatectomy in a laparoscopically naïve centre: a matched pair analysis. BJU Int 2009; 104: 991-995 5. Kim T, Kim DY, Cho MJ, Kim SC, Seo JJ, Kim IK. Use of laparoscopic surgical resection for pediatric malignant solid tumors: a case series. Surg Endosc 2010. DOI: 10.1007/s00464-010-1418 Prostate tumor Prostate tumor Fig 1 Fig 2 Embryonal Rhabdomyosarcoma Bladder floor 4B Tumor 4A Prostatic urethra Fig 3 Fig 4A, 4B. Cistoscopy with tumoral activity. Prostatic urethra, bladder floor. Cooper´s ligament Bladder Left ureter Bladder Fig 5. Retzius space. Pelvic floor. Fig 6. Left peritoneal fold. Bladder Left seminal vesicle Cooper´s ligament Vas deferens Rectum Rectum Right ureter Left ureter Fig 7. Right peritoneal fold. Fig 8 Urethra Bladder Right ureter Prostate Left ureter Denonvillier´s fascia Rectum Fig 9 Fig 10. The urethra is divided. Fig 11. Specimen