Applications of Laparoscopy and Minimally Invasive Techniques in Pediatric Urology
Anthony Balcom, MD, Assistant Professor of Urology
Pediatric urologic laparoscopy began in the mid-1980s, when laparoscopic evaluation of the non-palpable testis began, which facilitated accurate diagnosis and treatment of intra-abdominal testes. Shortly thereafter, many other applications of laparoscopy and minimally invasive techniques in pediatric urology occurred, the first of which was accurate placement of peritoneal dialysis catheters using laparoscopic guidance. This allowed us to place the dialysis catheters away from the omentum which would tend to plug the catheter. Laparoscopy then advanced to the point where we could accomplish complete laparoscopic orchidopexy successfully.
The treatment of ureteropelvic junction obstruction followed shortly thereafter — especially in children approximately seven years of age and older. The laparoscopic approach allows very precise reconstruction of the ureteropelvic junction after the excision of the stenotic segment, with minimal skin scarring, and very comparable hospital stay post-operatively. In fact, most authorities would now agree that the laparoscopic approach to the ureteropelvic junction obstruction in the older child is the preferred method.
Other procedures, such as varicocele ligation, nephrectomy for non-functioning dysplastic kidneys, especially the multicystic dysplastic kidney, ureteroneocystostomy, and partial nephrectomy for benign disease have been undertaken with good success by the pediatric urologic laparoscopist. At Children’s Hospital of Wisconsin, however, we have not undertaken laparoscopic ureteroneocystostomy, because we think we have superior success rates with a very small open Pfannenstiel type of “bikini line” incision. In the mid-teen patient, a laparoscopic ureteroneocystostomy would potentially be applicable.
As pediatric urologists, we also deal with inguinal hernias and hydroceles, and laparoscopy through the hernia sac to assess the contra-lateral processes vaginalis has also enjoyed useful application. In 1993, we were among the first in the country to incorporate laparoscopy via the hernia sac into our assessment of the contra-lateral side. The laparoscopic approach minimizes development of contra-lateral symptomatic inguinal hernias and hydroceles and minimizes repeat anesthetics for the child. We then evolved to pure laparoscopic hernia repair in boys and girls.
Some of the rare applications of laparoscopy in pediatric urology at Children’s Hospital of Wisconsin have been 1) the assessment of children with intersex anomalies, 2) staging of intra-abdominal malignancies such as lymphoma, and 3) neovaginoplasty in young women with vaginal hypoplasia. Particularly in those who have failed perineal pressure neo-vaginal dilatation, laparoscopic construction of a neo-vagina using the Vecchietti technique has been rewarding. Perhaps the laparoscopic procedure that has been the most beneficial to the child and his or her family is a laparoscopic continent cecostomy. This involves constructing a continent, catheterizable channel, typically using the vermiform appendix, through which the patient administers an antegrade enema. This is particularly applicable to the child with neurogenic bowel dysfunction from spina bifida. The child and the family can then plan bowel movements for at home, rather than the child having accidents at school, and the bladder benefits in terms of better capacity, with less urinary tract infections.
In summary, there are many applications of laparoscopy and minimally invasive surgical procedures in the field of pediatric urology. The age range of the child in whom laparoscopy is applicable has increased greatly in the past 15 years, and now, even one year olds are of sufficient body size to be potential laparoscopic candidates, specifically nephrectomy for multi-cystic dysplastic kidney. Laparoscopic pyeloplasty for UPJ obstruction would typically be considered for children four years old and older. Children benefit from less invasive surgical intervention, shorter post-operative hospital stay, improved cosmetic outcome, and less post-operative pain.