Second-look laparotomy for Wilms' tumor: indications and results in 19 patients

Nineteen of 74 children with Wilms' tumor underwent second-look laparotomy. Transperitoneal operation was done in five cases referred after flank operation elsewhere. Four had a change in stage from I to II or III, while one considered "inoperable" was resected (4/5 survived). Reoperation was done in two late referrals after operations with tumor spill. One had recurrent flank disease; the other had a flank mass with unrecognized diaphragmatic and intracaval extension (1/2 survived). Three children with giant tumors initially considered unresectable were successfully resected after cytoreduction with chemotherapy (3/3 survived). Two of three patients with bilateral Wilms' tumor survived reoperative procedures (partial or total nephrectomy). Five children with late intraabdominal recurrence (3 liver: 2 flank) eventually died despite reoperation and adjunctive therapy. All five had unfavorable histology. One child with en bloc hepatic resection had successful reoperation for suprahepatic vena caval obstruction due to regeneration of liver, but subsequently died. Ten of the 19 patients survived (52.6%) following reoperation and adjunctive therapy. Second-look laparotomy is quite useful in patients inadequately staged with flank operations, in cases of bilateral Wilms' tumor, and in children with initially unresectable tumors following cytoreduction. Patients with extensive tumor spill at a previous procedure may benefit from early reoperation. Late recurrence of tumor (especially with unfavorable histology) and/or liver metastases carried an ominous prognosis.