Prone retroperitoneoscopy in treating complex renal vascular malformations

IntroductionTwo children presented with malignant hypertension due to complex reno-vascular malformations. The 7-min video shows the use of prone retroperitoneoscopy in both.Patient 1A 6-year-old girl presented with convulsions and malignant hypertension. Captopril DMSA was suggestive of right renal artery stenosis. On formal angiography, the kidney was perfused by what appeared to be an arterio-venous malformation. The renal artery was hypoplastic and there were pulsatile vessels along the ureter due to the gonadal periureteric and gonadal inferior capsular collateral supply to the kidney. The kidney could be devascularized easily by controlling these.Patient 2A 14-month-old boy presented with 6-month history of poor appetite, weight loss and irritability. Formal angiography showed acute obstruction of the main upper pole branch. The vessels to the upper pole could be clearly seen and controlled at surgery for partial right nephrectomy. He recovered with no urine leak or bleeding.ConclusionGravity kept the renal vessels under stretch allowing excellent two-hand dissection and the space was adequate for suture closure of a calyx in Case 2. The prone approach provides excellent exposure of the renal blood vessels, aorta and vena cava, and seems to be the most suitable for complex renal vascular malformations.     

Acute renal papillary necrosis with complete bilateral ureteral obstruction in a child

A 9-year-old girl presented with apparent meningococcal septicemia and developed acute renal failure after 48 hours of treatment with antibiotics and analgesics. Early ultrasound scanning demonstrated mild bilateral hydronephrosis and hydroureter. Intravenous urography showed slow contrast uptake with delay nephrogram and no contrast entering the bladder. Repeat ultrasonography revealed bilateral papillary irregularity and echogenic debris in the distal ureters. Bilateral double-J stents were inserted cystoscopically, resulting in prompt polyuria and a return of normal renal function. Although rare, recognition of sloughed papilla in papillary necrosis causing ureteral obstruction can lead to early management with no long-term sequelae.     

Prone retroperitoneoscopic approach for heminephrectomy: Specific advantages relating to access to vascular pedicle

IntroductionThe lateral approach is more widely used in retroperitoneoscopic (RP) heminephroureterectomy (HNU) due to familiar orientation and ease of conversion. The prone approach however gives early and easy access to the vascular pedicle. The main reason for not adopting a prone approach more widely is the perceived difficulty in lower ureteric access. We present a series of 30 HNUs where the prone approach was utilized extremely effectively with no conversions and few complications.MethodsThirty consecutive HNUs performed over a 4-year period (2004–2007) using a prone RP approach were included in the study. Prospectively recorded data and notes were reviewed.ResultsUpper HNU was done in 17 and lower HNU in 13 patients. Mean age was 3.2 years (range 0.9–13.3). There were no transfusions or conversions. Follow-up ultrasound showed healthy remnant moieties in all. Residual ureteric stump was seen in six patients but only one was symptomatic requiring a further procedure.ConclusionWith the prone approach the anatomy can be demonstrated quickly and effectively. Dissection can be done easily without the need for kidney retraction as gravity aids demonstration of the renal vascular pedicle. There is a low risk of complications arising from the residual ureteric stump. We recommend that this approach be considered for RP HNU in all patients, irrespective of age.     

Outcome study of upper pole heminephroureterectomy in children

Objective  

We assessed the role and long-term outcome of upper pole heminephroureterectomy in the treatments of non-functioning upper renal moieties in children with duplex kidneys.     

Financial analysis of laparoscopic versus open nephrectomy in the pediatric age group

The authors compared the cost of laparoscopic nephrectomy to open nephrectomy in the pediatric age group. One hundred seventeen consecutive laparoscopic nephrectomies performed by a surgeon with extensive experience with this approach between April 2003 and August 2006 were included. A control group of 24 consecutive open nephrectomies performed by urologists who do not use the laparoscopic approach were also included. Inclusion criteria for surgery were a poor or nonfunctioning kidney related to severe obstructive or refluxing nephropathy and a multicystic dysplastic kidney. The length of operation, length of stay, and disposable equipment used were recorded and the different approaches were compared statistically with an unpaired t test. The mean (standard deviation [SD]) duration of the procedure was 79 minutes (32) in the laparoscopic group and 85 minutes (35) in the control group (P = 0.41). The mean (SD) cost of the disposable instruments used during the operation was pounds sterling274 (160) in the laparoscopic group and pounds sterling20 (5) in the control group (P = 0.0001). The mean (SD) hospital stay was 1 night (0.43) with a mean (SD) cost of pounds sterling677 (291) in the laparoscopic group, and 3 nights (2) with a mean (SD) cost of pounds sterling2031 (1354) in the control group (P = 0.0001). The mean (SD) total cost of the procedure was pounds sterling951 (451) for the laparoscopic group and pounds sterling2051 (1359) for the open one (P = 0.0001). In our experience, the laparoscopic approach in the pediatric age group is 54% less expensive than the open approach.     

Constant urinary dribbling due to an ectopic ureter and delays in diagnosis

We present 2 patients who had a solitary kidney visualized on ultrasound imaging and experienced constant urinary dribbling. Further imaging modalities defined the anatomy and visualized the contralateral kidney and ectopic ureter causing the dribbling. Both patients went on to have curative surgical procedures. These cases reinforce the point that in a toilet-trained girl with normal voiding at normal intervals experiencing constant urinary dribbling, the diagnosis of an ectopic ureter must be considered early and referral made for appropriate imaging. Because of the abnormal anatomy, ultrasound imaging is particularly limited in such cases, but if used, one should take account of antenatal and postnatal scans. Referral is advocated, based on history alone, for appropriate imaging and investigation.