Retroperitoneal laparoscopic nephrectomy in children: at last the gold standard?

We analyzed our experience with retroperitoneal laparoscopic nephrectomy giving special attention to the learning curve, morbidity, and feasibility in a teaching institution.

Between 1996 and 2004, we performed 104 laparoscopic nephrectomies in 88 children. Only four were performed via the transperitoneal approach, the others being via the retroperitoneal approach; the files of the latter were analyzed. Mean age was 5 years (20 days-15 years). Main indications were pretransplant nephrectomy for arterial hypertension, nephrotic syndrome or uremic hemolytic syndrome (51%), non-functioning kidney secondary to obstruction, reflux or ectopic ureter (38%), and multicystic dysplastic kidney (11%). Bilateral nephrectomy was performed in 13 children.

The lateral retroperitoneal approach was feasible in all cases even for those who had previous renal surgery. Conversion was not needed in any patient. No significant blood loss was observed. Mean operative time was 97 min (range 44-240) for unilateral nephrectomy; 46 nephrectomies were done in less than 90 min. In bilateral cases the mean operative time was 260 min (range 160-390). The operative time was less than 4 h in seven bilateral cases. Postoperative course was uneventful. Hospital stay was 1.9 days (range 1-3) for urological indications and 5 days (range 3-7) for patients with terminal renal disease. The procedure was initially performed by one surgeon, but was then expanded to other surgeons of the team, and safely taught to residents and fellows.

The procedure is safe, the learning curve is reasonable, teaching is feasible, operating time becomes with experience closer to open surgery without morbidity, and cosmetic results are excellent. This procedure may be considered as the gold standard for nephrectomy in children.