Laparoscopic retroperitoneal nephrectomy in high risk children

Nephrectomy may be indicated in children with end stage renal disease before transplantation. We studied the feasibility and results of nephrectomy performed via a retroperitoneal laparoscopic approach in these high risk children.

We performed 12 nephrectomies in 9 children with end stage renal disease and a mean age of 7 years (range 7 months to 13 years) through a 3 trocar retroperitoneal laparoscopic approach. Cases were classified as American Society of Anesthesiologists grade III and presented with end stage renal disease, hypertension, thrombocytopenia and/or the nephrotic syndrome. The renal artery and vein were ligated separately with endocorporeal knots and clips. Mean size of the kidney was 8 cm. (range 5 to 12). Bilateral nephrectomy was performed simultaneously in 2 patients 7 and 12 months old, respectively. Cardiorespiratory changes related to retroperitoneal gas insufflation were assessed prospectively. To compare laparoscopic versus open nephrectomy we retrospectively analyzed the data of 12 open nephrectomies performed in 9 children with similar nephrological indications.

The procedure was feasible in all cases without conversion to open surgery, and no intraoperative incident occurred. Mean operative time of laparoscopic nephrectomy was 2 hours (range 1 hour 20 minutes to 3 hours 10 minutes). After retroperitoneal carbon dioxide insufflation systolic arterial pressure and end-tidal carbon dioxide were significantly increased without the need for specific measure to correct these modifications. Hemodialysis began 1 day postoperatively and feeding began 2 days postoperatively. Mean hospital stay was 5.2 days (range 3 to 7). The comparative study of the open nephrectomy group showed no significant difference in mean operating time (p = 0.07), and hospital stay was significantly shorter for the laparoscopic group (p <0.001).

Retroperitoneal laparoscopic nephrectomy is safe and feasible for high risk children. The relatively long operating time is necessary for hemostasis in these children at risk for hemorrhagic complications.