Practical Laparscopy in Pediatric Urology

By Hossein Aliabadi, M.D., F.A.A.P., F.A.C.S.  


Table 1
Pediatric Laparoscopy Indications

Impalpable testis

Trauma

Varicocele

Biopsy

Intersex evaluation

Staging malignancies

Gonadectomy

Vague pelvic pain

Urachal evaluation

Vague abdominal pain

 


Table 2
Laparoscopy for Cryptorchidism

Diagnosis

Choice of incision

Staged orchiopexy

Orchiectomy

 

Figure 1
Laparoscopic appearance of a normal inguinal region.



Figure 2

Laparoscopic orchiopexy - First Stage. Clipping of the testicular vessels above the Stephen Fowler's membrane.

 

Figure 3
Laparoscopic appearance of a moderate-sized inguinal hernia.

 

Figure 4
Laparoscopic varix ligation in progress. The
metallic clips have divided the veins.

 

 

 

 

The application of laparoscopic principles in the diagnosis and treatment of many pediatric urologic conditions has gained tremendous popularity in recent years. This interest has been fueled by the success and acceptance of laparoscopic techniques in the adult population. While minimal access surgery offers a number of advantages for the adult patient, the distinction is less clear in the pediatric population, especially in infants and young children.

Many series and anecdotal reports have been published, describing of success for this technique, including laparoscopic nephrectomy, partial nephrectomy, ureteral reimplantation, laparoscopic autoaugmentation of the bladder, and mitrofanoff appendico-vesicostomy.1'2 While these techniques are being developed, it is difficult for us to justify their application in children where well-established, successful, and more cost-effective, open-surgical procedures exist without any compromise of the advantages currently attributed to laparoscopic techniques.1"3

      However, despite its limitations, laparoscopic procedures in infants, children and the adolescent age group do offer advantages in selected cases (Table 1). Laparoscopic techniques are particularly well-suited in such conditions, with benefits that clearly outweigh the associated risks. We employ pediatric urologic laparoscopy extensively in the management of nonpalpable testes, which occurs in about 20% of cases of cryptorchidism. Localization of the testicle in the intra-abdominal position by this technique helps us plan the appropriate intervention. If the vas deferens and the vessels are seen to course through the internal inguinal ring (Figure 1), it directs us to perform an inguinal incision and further helps in the choice of surgical technique (Table 2). If the vas deferens and spermatic vessels remain in an intra-abdominal position, arrangements can be made for a single- or multiple-stage orchiopexy for intra-abdominal testes or a microvascular testicular auto-transplant, which is utilized very infrequently. Our preference with high, intra-abdominal testes is to perform a two-stage Stephen Fowler's orchiopexy by clipping the testicular vasculature approximal to the Stephen Fowler's membrane, allow collateral circulation to develop, and then bring the testis down into the scrotal position in the second stage (Figure 2).

Laparoscopy is, therefore, quite helpful in providing information regarding the presence or absence of the testis, its location, and in planning for the appropriate surgical management. Additionally, the contralateral inquinal region can be inspected and if an asymptomatic indirect hernia is diagnosed it may be corrected at the same setting (Figure 3). Diagnostic laparoscopy also helps us define the pelvic anatomy in some cases of intersex disorders, associated with the presence of a dysgenetic gonadal issue, which may be removed successfully at the same time.

Diagnostic accuracy for localization of the nonpalpable testis by laparoscopic techniques has been extremely high in our experience and, therefore, employed routinely. In cases where the vas deferens and vessels traverse the inguinal ring and the testis is not palpable in the groin area, we routinely explore through the groin incision to locate the remnant vas deferens and vessels and to remove the vanished testis as evidence for histologic viable testicular tissue which may degenerate further, as seen in about 15% of all cases.

     We have also employed laparoscopy in the diagnostic evaluation and staging of pelvic malignancies such as rhabdomyosarcoma to help define the extent of the disease and lymphatic involvement. Biopsies can also be obtained at that time to assist in management. Use of laparoscopy in the evaluation of non-specific pelvic and abdominal pain is well-recognized in instances where other modalities of examination and imaging have been unrewarding, and to our knowledge, no specific pathologic conditions have been missed. In adolescent males who require ligation of varicocele, laparoscopic approaches are offered (Figure 4) in addition to traditional open-surgical repair. The morbidity rate appears to be equal or less than that for conventional open-surgical procedures, with a shorter recovery time. Complications are rare and we have not seen an increase in recurrence following laparoscopic varicocele ligation.

Complications are rare following laparoscopic procedures limited to these indications. We attribute this to careful patient selection and preparation, along with adherence to the basic principles of laparoscopic surgery and proper training. We have utilized laparoscopy in children ranging in age from 2 months to early adulthood with very favorable outcomes. Clearly, with further refinements in techniques, improved instrumentation and further experience, indications for laparoscopic procedures in pediatric urology will evolve to include new indications.

REFERENCES

1. Koyle MA, et al. Laparoscopic nephrectomy in the first year of life. J Fed Surgl993;28(5):693-5.

2. Peters CA. Laparoscopy in pediatric urology. Urol 1993;41:33-7.


3. Bloom DA. Two-step orchidopexy with pelviscopy clip ligation of the spermatic vessels. J Urol 1990;144:1030.

4. Aliabadi HA, Wolpert JJ, Reinberg Y. Short-stay nephrectomy in infancy. Abstract 87:34, Eighth Annual Meeting of the European Society for Pediatric Urology', Rome, Italy, 1997.

5. Diamond DA, Caldamone AA. The value of laparoscopy for 106 impalpable testes relative to clinical preservation. J Urol 1992;148:632-4.

Direct inquiries to: Drs. Aliabadi, Wolpert and Reinberg, Pediatric Surgical Associates, Section of Urology, 2545 Chicago Avenue South, Suite 104, Minneapolis, MN 55404; telephone 612/813-8000 or 800/992-6983. Or Childrens Center for Pediatric Urology, 612/813-6262 or 800/CPU-6262.

 

 

 

 

 

 

 

 

 

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