Pediatric Surgery Department, Garrahan Hospital, Buenos Aires, Argentina.
Pediatric Surgery Department, Garrahan Hospital, Buenos Aires, Argentina.
J Pediatr Urol. 2018 Oct;14(5):388-393. doi: 10.1016/j.jpurol.2018.06.015. Epub 2018 Jul 23.
Laparoscopic total nephrectomy (LN) in malignant pediatric tumors remains controversial. For selected patients undergoing pre-operative chemotherapy in referral centers, LN has so far shown comparable results to the standard open technique.
To describe the inclusion criteria and preliminary results of laparoscopic nephrectomies (LN) for the treatment of unilateral Wilms tumors (WT).
Between November 2010 and January 2016, a retrospective study of patients with WT and undergoing pre-operative chemotherapy was performed. Inclusion criteria for candidates for LN were: unilateral tumors without venous invasion and central kidney localization. Tumor size and vascular thrombus were estimated with pre-operative computed tomography (CT) scan. Overall survival and recurrence rates were evaluated.
Among 105 patients with WT, 14 underwent LN. Tumor bleeding or the lack of response to chemotherapy were not exclusion criteria. Median tumor volume for the patients undergoing LN was 71.5 cc (range 7-169). Patients with small tumors localized near the renal pole and candidates for nephron sparing surgery (NSS) were excluded. Estimated 5-year overall survival for all patients with WT during this period was 88.7% (88.1-103.1). Two patients underwent conversion. No recurrence or related death was found at a mean 32- month follow-up period.
Reproducing the steps of the open nephrectomy when performing LN for malignant tumors allowed comparable oncologic results to the conventional procedure. However, upstaging of the tumor was not admissible and has become the main goal when approaching these patients laparoscopically. Preliminary results showed that the incidence of intraoperative rupture and incomplete node sampling were not an issue when comparing LN to open nephrectomy. On the other hand, LN for malignant tumors requires experience in advanced laparoscopy and oncologic surgery. Pre-operative chemotherapy changes the tumor's consistency and this is the key point as to why these patients are amenable to be approached laparoscopically. Lifting the tumor along with the fat to avoid capsule fraction, as well as changing the lens to the lateral port to achieve a correct view for lymph node sampling are some of the considerations when performing LN.
Preliminary data suggest that LN for WT is feasible and has promising results in terms of event-free and overall survival. In patients undergoing pre-operative chemotherapy the correct selection for LN is crucial. Following the basic oncological precepts and in experienced centers, LN represents a plausible modality in the care of these patients.
腹腔镜全肾切除术（LN）在小儿恶性肿瘤中仍存在争议。对于在转诊中心接受术前化疗的选定患者，LN 迄今已显示出与标准开放技术相当的结果。
描述用于治疗单侧威尔姆斯瘤（WT）的腹腔镜肾切除术（LN）的纳入标准和初步结果。
2010 年 11 月至 2016 年 1 月，对接受术前化疗的 WT 患者进行了回顾性研究。LN 候选者的纳入标准为：无静脉侵犯和中央肾定位的单侧肿瘤。肿瘤大小和血管血栓形成通过术前计算机断层扫描（CT）扫描进行评估。评估总生存率和复发率。
在 105 例 WT 患者中，14 例行 LN。肿瘤出血或对化疗无反应不是排除标准。行 LN 的患者的肿瘤体积中位数为 71.5cc（范围 7-169）。排除了靠近肾极的小肿瘤和候选保肾手术（NSS）的患者。在此期间，所有 WT 患者的估计 5 年总生存率为 88.7%（88.1-103.1）。两名患者转为开放手术。在平均 32 个月的随访期间，未发现复发或相关死亡。
在为恶性肿瘤行 LN 时，重复开放肾切除术的步骤可获得与传统手术相当的肿瘤学结果。然而，肿瘤分期的升高是不可接受的，当以腹腔镜方式接近这些患者时，这已成为主要目标。初步结果表明，在比较 LN 与开放肾切除术时，术中破裂和不完全淋巴结取样的发生率不是问题。另一方面，恶性肿瘤的 LN 需要在高级腹腔镜和肿瘤外科方面的经验。术前化疗改变了肿瘤的一致性，这是这些患者适合腹腔镜处理的关键。沿着肿瘤和脂肪提起以避免包膜破裂，以及将镜头切换到侧端口以获得正确的淋巴结取样视图是进行 LN 时需要考虑的一些因素。
初步数据表明，WT 的 LN 是可行的，在无事件和总生存率方面具有良好的结果。在接受术前化疗的患者中，正确选择 LN 至关重要。在经验丰富的中心遵循基本的肿瘤学原则，LN 代表了这些患者护理的一种可行模式。
