Minimally invasive open renal surgery

Improved pediatric laparoscopic techniques and instruments have led to the increased popularity of laparoscopic pyeloplasty and nephrectomy at some centers. The recent trend has compared laparoscopic to open techniques to draw parallel conclusions from the adult literature that laparoscopic surgery in children offers the same advantages. Historically open renal surgery in the pediatric population has been done successfully but usually through more traumatic incisions. We present our experience with minimally invasive open renal surgery.

A retrospective review of the last 6 years was performed of consecutive open pyeloplasties for ureteropelvic junction obstruction and open nephrectomy for multicystic dysplastic kidneys and renal duplication anomalies at a tertiary hospital for children. Parameters evaluated were patient age at surgery, surgical incision size, operative time, hospital stay and the need for postoperative narcotics.

A total of 135 patients underwent open renal surgery using an open retroperitoneal flank incision, including 66 younger than 1, 32 who were 1 to 5, 11 who were 5 to 10 and 26 who were older than 10 years. Mean +/- SD operative time was 101.4 +/- 44.7 minutes in patients younger than 1 year, 87.7 +/- 39.3 minutes in those 1 to 5 years old, 127.1 +/- 62.7 minutes in those 5 to 10 years old and 127.8 +/- 38.4 minutes in those older than 10 years. Incision size for the groups was 1.9 +/- 0.61, 1.9 +/- 0.72, 3.0 +/- 1.3 and 3.8 +/- 1.6 cm, respectively. The last 20 patients younger than 1 year who underwent open pyeloplasty had an incision of between 1 and 1.5 cm. Most incisions were performed through a posterior, subcostal muscle splitting approach. All patients received postoperative ketorolac. Supplemental narcotics were not required in any patients younger than 10 years. Of the patients 90% were discharged home in less than 23 hours.

The minimally invasive approach to open renal surgery is a safe and effective treatment choice in pediatric urology. The procedure can be easily performed through a small incision with minimal morbidity, comparable operative time and excellent cosmesis without excessive postoperative pain issues, allowing early discharge home. Perhaps this refined open surgery technique should be the benchmark for comparing new techniques.