Leclair Marc-David, Vidal Isabelle, Suply Etienne, Podevin Guillaume, Héloury Yves
Pediatric Surgery Department, Hôpital Mère-Enfant, Nantes, France.
Eur Urol. 2009 Aug;56(2):385-9. doi: 10.1016/j.eururo.2008.07.015. Epub 2008 Jul 16.
Laparoscopic retroperitoneal partial nephrectomy in children remains a complex technique with limited diffusion among the paediatric surgical community.
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.
Retroperitoneal laparoscopic partial nephrectomy for duplex kidney in lateral position (n=31) and prone in the last 17 cases.
We assessed intraoperative and postoperative morbidity. Follow-up (median 14 mo, range 6-125 mo) was based on clinical review and renal ultrasound.
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.
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.
儿童腹腔镜腹膜后部分肾切除术仍是一项复杂技术，在小儿外科领域应用有限。
报告我们在儿童和婴儿中应用该技术15年的腹腔镜半肾切除术经验。
设计、场所、参与者：本单中心研究回顾性纳入48例行腹膜后腹腔镜部分肾切除术的儿童（36例上极肾切除术[UPN]和12例下极肾切除术[LPN]）。手术时的中位年龄为8.6个月（范围1.5 - 89个月），对于涉及上尿路严重扩张的UPN病例采取早期手术干预策略。
31例侧卧位行腹腔镜腹膜后双肾半肾切除术，最后17例俯卧位。
我们评估了术中及术后发病率。随访（中位时间14个月，范围6 - 125个月）基于临床检查和肾脏超声。
手术中位时长为120分钟（范围71 - 215分钟）。10例手术（21%）转为开放手术，大多在经验积累初期（前20例中有8例，而后20例中仅1例转为开放手术）。在4例转为开放手术的LPN中，3例因实质切开困难而转为开放手术。6例UPN因暴露困难而转为开放手术，这与年龄密切相关：所有6例均为婴儿，中位年龄为3.25个月（范围1.5 - 8个月）。我们观察到1例（病例4）剩余下部分肾功能丧失。
本研究显示腹腔镜半肾切除术在学习曲线阶段的中转率较高。腹膜后腹腔镜UPN在儿童中仍是一项具有挑战性的手术，尤其是在集合系统严重扩张的小婴儿中。对剩余部分造成血管损伤的可能性要求在肾蒂解剖时非常谨慎，当无法清晰看清血管解剖结构时应转为开放手术。
