Laparoscopic Pediatric Urology
The major advances in laparoscopic urologic surgery began with pediatric applications. Laparoscopy has raised great interest in the past few years in the field of pediatric urology. It has evolved from a simple diagnostic maneuver to complex operative procedures. With respect to current indication for laparoscopy in pediatric urology, several well-established clinical procedures like treatment of varicocele, nonpalpable testis, the current data suggest that laparoscopic surgery is a safe and feasible technique in pediatric urology if performed by expert surgeons and that it certainly will develop further in the next few years.
The first laparoscopic urologic applications were in the localization of an impalpable undescended testicle. This technique became the definitive diagnostic and first operative step in the management of this condition. Laparoscopy offered a 97 percent chance of finding a testicle or proving its absence. Recent advances in endoscopic and accessory instrumentation have allowed the urologist to expand the role of laparoscopy in the pediatric population. In some respects, children may be better suited for laparoscopic procedures than adults because of their decreased intraabdominal and retroperitoneal fat.
The main problem in pediatric laparoscopic urology is the choice of the most suitable way to reach the urinary tract. Until a few years ago, the transperitoneal route was the only route to the kidney and the urinary tract. In general, surgeons prefer the transperitoneal approach at the beginning of their experience in pediatric laparoscopic urology because of the well-known and wide peritoneal chamber. Usually, four to five ports are necessary and, after the colic angle is detached and Told’s fascia is opened, the kidney and upper urinary tract are easily identifiable. The lower urinary tract, the testis, and the spermatic vessels also can be treated using this approach. Retroperitoneoscopy, also called lumboscopy, follows all the criteria of open renal surgery, respecting the integrity of the peritoneal cavity.
Currently, laparoscopy has been used in pediatric urology for:
• Localization and evaluation of impalpable undescended testicles
• Gonadal examination and biopsy in patients with intersex disorders
• Orchiectomy for undescended testicles
• Diagnosis and treatment of pediatric inguinal hernias
• Staged orchiopexy
• Spermatic vein ligation in patients with a varicocele
• Retarded testicular growth
There are several important factors to consider when operating in the pediatric patient. First, there is a relatively short distance between the anterior abdominal wall and the great vessels. Thus, the margin for error in pediatric laparoscopy is inversely proportional to the age and size of the patient. Trocars and needles must not be passed too deeply to avoid vascular injury. Also, the child has a thinner abdominal fascia requiring less pressure to introduce the veress needle and trocars into the abdomen. In addition to this, the pelvic anatomy differs in infants and young children. A large portion of the bladder is located outside the bony pelvis. Prompt decompression of the bladder with a catheter before a veress needle is essential to avoid a bladder perforation. Also, much less carbon dioxide gas is required in the child, as the peritoneal cavity is small compared to that of an adult.
Children’s dimensions are well suited to laparoscopy. Landmarks are readily identifiable and palpable. For example, the bifurcation of the great vessel as well as the sacral promontory are usually easily felt. In addition, abdominal or pelvic masses are easily detected in most children.