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Keywords:

  • laparoscopy;
  • posterior prone;
  • peritoneal dialysis;
  • end-stage renal disease

Abstract

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. PATIENTS AND METHODS
  5. RESULTS
  6. DISCUSSION
  7. CONFLICT OF INTEREST
  8. REFERENCES

OBJECTIVE

To describe a laparoscopic approach for bilateral synchronous posterior prone retroperitoneoscopic nephrectomy (BSPPRN) which allows for immediate peritoneal dialysis (PD) in children with end-stage renal disease (ESRD), as PD is the treatment of choice in these children with ESRD who are awaiting renal transplantation.

PATIENTS AND METHODS

Traditionally, children requiring bilateral native nephrectomy have been managed on haemodialysis before being converted to PD at a later stage, but this approach incorporates a conventional open transperitoneal nephrectomy, which had associated morbidity. Between May 2001 and December 2005, 20 children had BSPPRN with initiation or return to PD immediately afterward (mean age at surgery 8.5 years, range 0.5–17). The indications for surgery included steroid-resistant proteinuria in 14, drug-resistant hypertension in four, proteinuria and hypertension in one and intractable polyuria in one. BSPPRN used either three or two ports, or the ‘single-instrument port’ technique. A PD catheter was placed simultaneously in eight children, whilst 10 were already established on PD.

RESULTS

BSPPRN was successful in 19 children; one developed a peritoneal tear, which necessitated conversion to open nephrectomy. The mean (range) operative duration was 160 (110–180) min. There were no major complications and no child required a blood transfusion. PD was established immediately after surgery in 17 children; one had a dialysate leak requiring a period of haemodialysis.

CONCLUSION

In children who require bilateral native nephrectomy before renal transplantation, BSPPRN maintains the integrity of the peritoneal cavity, allowing for immediate PD after surgery. The technique is safe and has all the added advantages of minimally invasive surgery.


Abbreviations
BS(PP)(R)N

bilateral synchronous (posterior prone) (retroperitoneoscopic) nephrectomy

PD

peritoneal dialysis

ESRD

end-stage renal disease

INTRODUCTION

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. PATIENTS AND METHODS
  5. RESULTS
  6. DISCUSSION
  7. CONFLICT OF INTEREST
  8. REFERENCES

Native nephrectomy is required before renal transplantation for various medical reasons in a selected group of children with end-stage renal disease (ESRD). Traditionally, this has involved a conventional open approach, which can be associated with significant morbidity [1]. With technological advances in minimally invasive surgery and expertise, laparoscopic nephrectomy is a well established technique in paediatric surgical practice and has been described in adult patients with ESRD [2].

Peritoneal dialysis (PD) is the preferred option for a child awaiting renal transplantation, due to the high morbidity associated with haemodialysis [3]. The traditional approach to this problem has therefore been open bilateral native nephrectomy with a period of haemodialysis to allow the peritoneum to heal, followed some months later by placing a PD catheter.

Here we describe our unique bilateral synchronous posterior prone retroperitoneoscopic nephrectomy (BSPPRN) approach, which maintains the integrity of the peritoneal cavity, allowing for immediate PD after surgery.

PATIENTS AND METHODS

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. PATIENTS AND METHODS
  5. RESULTS
  6. DISCUSSION
  7. CONFLICT OF INTEREST
  8. REFERENCES

Between May 2001 and December 2005, 20 children with ESRD had BSPPRN with initiation or return to PD immediately after surgery (mean age at surgery 8.5 years, range 0.5–17). The mean (range) renal length, as measured by ultrasonography, was 7.5  (2–14) cm. The indications for surgery included steroid-resistant proteinuria in 14, drug-resistant hypertension in four, proteinuria and hypertension in one and intractable polyuria in one.

The evaluation before surgery included ultrasonography to measure the dimensions of the kidneys, and a careful examination of the child for suitability for PD. The dimensions of the kidneys determine whether an endopouch will be required to remove the specimen(s). The child is placed fully prone, with the chest and abdomen raised to allow the abdomen to lie in a dependant position (Fig. 1). The retroperitoneum is accessed through a 5–10 mm incision at the lateral border of the sacrospinal muscle, midway between the superior border of the iliac crest and the inferior border of the 12th rib (Fig. 2). Balloon dissection of the retroperitoneum is done with a homemade balloon inserted through this incision. Pneumoretroperitoneum is maintained with carbon dioxide at 10–12 mmHg throughout the procedure. The 5-mm secondary port(s) are placed under laparoscopic vision in the position(s) shown in Fig. 2. In the latter part of series, we used one secondary port for the entire procedure (single-instrument port laparoscopic nephrectomy) [4]. Once the kidney is identified, the renal vessels are controlled first and then the ureter and kidney are mobilized completely. The specimen is usually placed in an ‘endobag’ and removed piecemeal through the 10-mm port. The same technique is used on each side.

image

Figure 1. The complete prone position.

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Figure 2. The position of the ports.

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In eight children, under the same anaesthetic, a PD catheter was placed in a standard tunnelled fashion, with the patient supine. Ten children already had a functioning PD catheter in situ. Two children were on haemodialysis, one for previous multiple abdominal procedures and the other had recurrent episodes of peritonitis.

All children were allowed oral fluids and diet as tolerated immediately after surgery. PD was commenced within 24 h after completing surgery. The PD catheter was initially flushed with dialysate fluid until the return fluid was clear, before commencing dialysis.

RESULTS

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. PATIENTS AND METHODS
  5. RESULTS
  6. DISCUSSION
  7. CONFLICT OF INTEREST
  8. REFERENCES

BSPPRN was successful in 19 children; one needed open conversion unilaterally, due to a tear in the peritoneum. The mean (range) operative duration was 160 (110–180) min, which included the time required to place the PD catheter in eight patients. None of the children required a blood transfusion and there were no complications. PD was established within 24 h in 15 children; in two the start of PD was delayed by 48 h, due to a catheter breach and a fever, respectively. In one child, a continuous peritoneal leak required a temporary period of haemodialysis to allow the leak to seal.

At the last follow-up, the 14 children with proteinuria (plus one combined indication) had a normal plasma albumin level. The four children (plus one combined indication) with drug-resistant hypertension are normotensive with no need for medication. The child with polyuria no longer requires overnight fluid replacement.

DISCUSSION

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. PATIENTS AND METHODS
  5. RESULTS
  6. DISCUSSION
  7. CONFLICT OF INTEREST
  8. REFERENCES

A bilateral native nephrectomy before transplantation is indicated in ESRD when it is associated with persistent proteinuria, drug-resistant hypertension, intractable polyuria or a combination of these [5]. Traditionally the bilateral nephrectomy is done through a midline incision or bilateral loin incisions. This approach carries a significant risk of morbidity (40–58%) and mortality (3–11%), as reported by Yarimizu et al.[1]. Since the first description of a laparoscopic approach for nephrectomy in 1993 by Das et al.[6] this approach has become popular for both benign and malignant conditions of the kidney. Some surgeons use a transperitoneal route whilst others prefer the retroperitoneoscopic route.

Ismail et al.[7] described their experience in adults with simultaneous single-incision bilateral native nephrectomy and renal transplantation vs staged laparoscopic bilateral nephrectomy followed by renal transplantation. They found that >60% of the former group required an additional surgical procedure, whilst those in the latter group had no major complications. They concluded that laparoscopic bilateral nephrectomy followed by kidney transplantation is safe and feasible.

Gill et al.[8] favoured a retroperitoneoscopic approach for bilateral nephrectomy, again in adults, and found that using this approach there was less requirement for analgesic after surgery, and a shorter hospital stay than for a similar group having an open procedure. However, the incidence of complications was similar in both the open (40%) and laparoscopic (50%) groups.

The first description of bilateral laparoscopic nephrectomy in children was in 2000, when York et al.[9] reported two children having bilateral transperitoneal laparoscopic nephrectomy. Two years later Fujisawa et al.[10] reported the first retroperitoneoscopic bilateral nephrectomy in a child with ESRD managed by PD. In 2004, we described the encouraging experience in three children who had BSRN with simultaneous PD [11]. We showed that it is possible to perform a bilateral laparoscopic nephrectomy and start PD immediately afterward. PD is the preferred option for renal-replacement therapy in children, due to the high morbidity associated with haemodialysis. It is well tolerated and as it is usually done overnight there is minimal disruption of the child’s daily routine, particularly schooling [12–14].

Our preferred technique for laparoscopic nephrectomy is the PPR approach, as it maintains the integrity of peritoneum. This has the added advantage, in this group of patients, of allowing for the initiation of PD in the first 24 h after surgery.

There are several technical points that need to be considered when using this approach. When planning the operation, consideration should be given to the size of the camera port. In most cases, particularly those with congenital nephrotic syndrome, the kidneys are bulky and fibrotic, and require entrapment in an endopouch for removal. The camera port should therefore be 10 mm in diameter to accommodate the 10 mm pouch-retrieval system. When creating the retroperitoneal working space the dissecting balloon must be inflated slowly to avoid a tear in the peritoneum. This is particularly important in those children already established on PD, where the peritoneum is very thin, delicate and easily breached. Meticulous haemostasis is paramount and care must be taken to use diathermy on even the smallest of vessels, as bleeding can significantly compromise the vision in an already limited working space. The specimen must be entrapped gently and with good laparoscopic vision. Attention must be focused on the metal tip of the pouch, which can cause a tear in the peritoneum.

With our increasing experience in the latter part of the present series we used a single-instrument port for the entire procedure. This is termed ‘SIMPL’ (single-instrument port laparoscopic) nephrectomy and has been described previously [4]. This has the advantage of avoiding a third incision for the second medially placed instrument port, and thereby the potential for less postoperative pain. We have not found that using this technique prolongs the operative time.

In our series of 20 patients (40 kidneys) we successfully completed the nephrectomy laparoscopically in 19 (39 kidneys). In the child who required conversion to open surgery, a PPR nephrectomy was used successfully on one side, and when creating the working space on the contralateral side there was a breach in the peritoneum. This significantly compromised the working space and the nephrectomy was completed as an open operation. This child was an infant, weighing only 6 kg, with congenital nephrotic syndrome and relatively large kidneys. These factors collectively would make this a technically difficult case from the start.

The peritoneal tear was in a child with a large kidney and nephrotic syndrome. Creating the space was a problem due to inadequate insufflation of the balloon. We suggest avoiding this by slow and careful insufflation of the balloon, and sometimes repeat insufflation. A cautious approach is needed for infants, in view of limited space with large kidneys, because open conversion will add to the morbidity. In the present series we successfully completed the procedure in one of two infants.

Although it was recommended to use dialysis shortly before surgery to delay dialysis afterward, the retroperitoneoscopic approach allows dialysis immediately after surgery [15]. In the present series dialysis was initiated within 24 h in 15 children; in two it was delayed to 48 h due to a catheter breach (one) and pyrexia (one) requiring antibiotics. Only one child required haemodialysis temporarily due to a persistent peritoneal leak around the exit site of the catheter. This problem might have resulted from poor operative technique or might have been a consequence of poor healing secondary to hypoproteinaemia [16].

Sixteen of the present children have subsequently had a renal transplant into the right iliac fossa. The surgical field in all cases was noted to be pristine, with no evidence of adhesions between the peritoneum and pelvic side-walls and/or the major vessels. This might be an additional benefit of the retroperitoneoscopic approach.

In conclusion, we are encouraged by the BSPPRN technique in children; it allows for PD shortly after surgery and avoids the need for haemodialysis. This is an important consideration in the long-term management of children with ESRD. The technique was safe and well tolerated in this selected group of children, but it requires considerable experience with laparoscopic surgery and strict adherence to several technical points to ensure success.

REFERENCES

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. PATIENTS AND METHODS
  5. RESULTS
  6. DISCUSSION
  7. CONFLICT OF INTEREST
  8. REFERENCES
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