Technique of laparoscopic transperitoneal lower pole heminephroureterectomy.

BACKGROUND

Laparoscopic transperitoneal nephrectomy is technically feasible in most cases of benign renal disease. To date, there have been isolated reports of laparoscopic transperitoneal heminephroureterectomy of principally the upper moiety of a duplex system. Rarely reported are lower moiety nephroureterectomies.

AIM

The aim of this IPEG submission is to present a 3-minute video demonstrating the technical details of a transperitoneal laparoscopic, right, lower moiety, heminephroureterectomy in a 3-year-old. METHODS/TECHNIQUES: A child with marginally functioning (<5%) lower moiety of a right duplex system was subjected to a transperitoneal heminephroureterectomy. The patient was placed in a left lateral position and an umbilical camera and two working ports (right iliac fossa, epigastric), all 5 mm, were utilized. The ascending colon was reflected to the left and the underlying lower moiety ureter identified and isolated. With traction on the ureter, the pelvis was brought into view and control of blood supply to the lower moiety was achieved by using a combination of ultrasonic scalpel and hook diathermy. A critical step at this stage was definition of the superior limit of the pelvis, which corresponded to the level of vascular demarcation. The renal parenchyma was transected at this point by using the ultrasonic scalpel, which ensured reasonable hemostasis. Complete hemostasis was assured by approximating the divided kidney with a series of three interrupted intracorporeal sutures. The subtending ureter was dissected close to the bladder base, where it was ligated and divided. A drain was placed percutaneously in the renal bed and the specimen retrieved via an extended umbilical incision.

RESULTS

The patient was started on fluids on recovery with oral feeds introduced the next morning. The drain was removed prior to discharge on day 2. At 6 months post-resection, the patient remains well.

CONCLUSION

Laparoscopic transperitoneal lower pole heminephroureterectomy is technically feasible for benign renal disease in children. The combination of ultrasonic scalpel and intracorporeal suturing is adequate to control bleeding of the transected kidney. Dissection of the ureter distally to bladder neck is easily achieved without change in port position. Recovery is robust with minimal requirement for analgesia. The wider space, better view, and ability to access all of the urinary tract make this a tenable alternative to other laparoscopic approaches.