La laparoscopia nella patologia delle vie urinarie Università degli Studi di Napoli “Federico II” Dipartimento di Pediatria Cattedra di Chirurgia Pediatrica Direttore: Prof. Alessandro Settimi La laparoscopia nella patologia delle vie urinarie

In the last years ,renal pathologies are also beginning to be dealt with using laparoscopic procedures Urological videosurgical procedures represent only 5-10% of all videosurgical interventions

Two routes are usually used transperitoneal retroperitoneal

The TRANSPERITONEAL route is easier, because it allows the surgeon to work in a wider cavity as the more familiar peritoneal chamber

The RETROPERITONEAL route can be more difficult due to the small operating chamber It meets all the criteria of open renal surgery

INDICATIONS Nephrectomy Heminephrectomy Renal cyst resection Stone removal Ureterocutaneostomy Adrenalectomy Renal biopsies

LAPAROSCOPIC UROLOGY TROCARS 5-mm Retractor 10-mm Optic 5-mm 10-mm 1st operative 5-mm 2nd operative

LAPAROSCOPY TRANSPERITONEAL ROUTE

RETROPERITONEOSCOPY

RETROPERITONEOSCOPY

PATIENT SET-UP

RETROPERITONEAL CHAMBER Posterior axillary line Between 12th rib and iliac crest

BALOON DISSECTION

OPTIC DISSECTION DIGITAL DISSECTION

RETROPERITONEOSCOPY TROCARS 10-mm Optic 5-mm 2 nd operative 5-mm 1st operative 5-mm

BALLOON TROCAR

RETROPERITONEAL NEPHRECTOMY Patient in a lateral decubitus 3 trocars Retroperitoneal chamber, balloon trocar Kidney and ureter isolated Vessels sectioned between clips or ligatures Kidney removed through optique orifice

WORKING SPACE

KIDNEY

URETER

HILAR VESSELS

ADRENALECTOMY The adrenal tumors in children are often large , malignant and infiltrative Very few experiences have been reported Experience of each team is limited to less than 4 cases

ADRENALECTOMY #2 Indications Benign lesions ( Adenoma, hyperplasy, cysts) Selected cases of malignant tumors Size < 6 cm in adolescents and < 3 cm neonates No age limits

ADRENALECTOMY

RESULTS Laparoscopy: adhesions, infection Operating time:30 120 minutes (70mns) Laparoscopy: adhesions, infection Lomboscopy: peritoneal perforation

CONSIDERATIONS More direct and fast Less trocars Avoid problems of adhesions due to previous abdominal surgery Limited working space Needs habit and skills Could be a disadvantage in case of complications

LEGAL ASPECTS - Informated Consensus - Before each procedure - Both the parents

CONCLUSIONS The retroperitoneal route is preferable when approaching renal pathologies as in traditional open surgery Laparoscopic transperitoneal experience necessary