Retroperitoneal Laparoscopic Heminephrectomy in Duplex Kidney in Infants and Children: A 15-Year Experience

Background: Laparoscopic retroperitoneal partial nephrectomy in children remains a complex technique with limited diffusion among the paediatric surgical community. Objective: To report our experience with laparoscopic heminephrectomy in duplex kidneys after a 15-yr practise of the technique in children and infants. Design, setting, participants: Forty-eight children with retroperitoneal laparoscopic partial nephrectomy (36 upper-pole nephrectomies [UPN] and 12 lower-pole nephrectomies [LPN]) were retrospectively included in this single-institution study. Median age at surgery was 8.6 mo (range 1.5-89), with a policy of early surgical intervention for UPN in cases involving a massively dilated upper tract. Intervention: Retroperitoneal laparoscopic partial nephrectomy for duplex kidney in lateral position (n = 31) and prone in the last 17 cases. Measurements: We assessed intraoperative and postoperative morbidity. Followup (median 14 mo, range 6-125 mo) was based on clinical review and renal ultrasound. Results and limitations: Median duration of surgery was 120 min (range 71-215). Ten procedures (21%) were converted into open surgery, mostly at the beginning of the experience (eight during the first 20 cases, as compared to one conversion in the last 20). Among four converted LPNs, three were converted for difficulties during parenchymal section. Six UPN were converted for difficulties of exposure, with a strong correlation with age: all six were infants, with a median age of 3.25 mo (range 1.5-8 mo). We observed one case (case 4) of functional loss of the remaining lower moiety. Conclusions: This study shows a high conversion rate during the learning curve for laparoscopic heminephrectomy. Retroperitoneoscopic UPN remains a challenging procedure in children, especially in small infants with very dilated collecting systems. The possibility of vascular damage to the remaining moiety warrants a very cautious dissection of the renal pedicle and should lead to conversion when clear visualization of vascular anatomy is not ascertained. (C) 2008 European Association of Urology. Published by Elsevier B.V. All rights reserved.