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300 Longwood Avenue
Boston, MA 02115
(617) 355-6000
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My Child Has:
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Minimally Invasive Surgical Procedures used to correct disorders of the Genitourinary System
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The term "minimally invasive surgery" describes a variety of surgical techniques that do not require making a large incision in the body to correct the problem or remove tissue. Some of these methods have been used for many years in urology, such as cystoscopy (looking and operating inside the bladder through a small telescope passed through the urethra or urinary passage), while others are more recent developments, particularly laparoscopy.
Endourology is the general term used to describe minimally invasive methods using scopes placed into parts of the urinary tract and includes cystoscopy, ureteroscopy or nephroscopy. They may be through natural openings such as the urethra, or through a puncture of the skin such as used in nephrosocopy. Laparoscopy involves telescopes placed into the body but these methods usually use several other puncture sites as well, to permit actual surgical manipulations of tissues, removal of tissues, and reconstruction similar to what would be done with conventional open surgery with an incision.
Laparoscopy is performed at all ages and under general anesthesia. In all techniques, the area where the surgery is to be performed is seen through a telescope inserted into the body through a small puncture (usually less than 5 mm long) and the work area is enlarged by putting carbon dioxide into the body cavity. This provides for a wide view of the area to be operated upon. The telescope provides a light and magnifies the view as well. Separate puncture sites are then made to allow surgical tools to be passed into the area of surgery to perform the operation. These instruments permit the surgeon to hold, cut, and sew tissues, as well as control bleeding. At the end of the procedure, the carbon dioxide is allowed to escape from the body and the instruments are removed. The puncture sites are usually closed with a single stitch and a small bandage.
The advantages of laparoscopy are that there is no large incision, there is usually less discomfort after surgery and patients are able to return home sooner. The disadvantages are that the operations may take longer to perform in some situations, although this is changing as more laparoscopy is being performed. Occasionally (less than 1 or 2%), a laparoscopic operation must be changed to an open operation if the surgeon does not feel that the procedure can be completed effectively or safely using laparoscopy.
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In some conditions a kidney that does not work very well needs to be removed to prevent infection, high blood pressure (hypertension), or pain. Laparoscopic nephrectomy can be used to do this at any age. The operation has been performed from the front (transperitoneal) or from the back or side (retroperitoneal). Most kidneys can be removed using the retroperitoneal approach, which seems to permit even more rapid recovery. If the ureter (the tube connecting the kidney with the bladder) needs to also be removed, the transperitoneal approach is sometimes better. If a child has had many kidney infections or if there is a kidney tumor, laparoscopic removal is not recommended.
When the kidney is to be removed laparoscopically, it is performed under general anesthesia and three or four punctures are used. The kidney is removed through one of the puncture sites, sometimes using a small bag inserted into the surgical area to allow the kidney to be pulled out. The operation takes about 2 or 3 hours and children usually go home the next morning. This procedure can be done in infants as well as teenagers and adults.
In some children, only a part of the kidney must be removed and this may also be performed using laparoscopic techniques. This is called a partial nephrectomy, and may require slightly more time for surgery. Most of these children may go home within 24 hours.
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When the kidney is obstructed, it may be necessary to perform an operation to correct the obstruction by removing the narrow part of the tube and re-connect the kidney's drainage system. The obstruction is usually near the kidney at what is called the ureteropelvic junction. The operation to correct this problem is called a pyeloplasty and may also be performed laparoscopically using robotic surgery equipment. The open surgery is usually performed through a cut in the side, just under the ribs, or in the back under the rib. Children usually stay in hospital for three days.
Robotic-assisted laparoscopic surgery may take longer, but children usually can go home 24 to 48 hours after surgery.
The success rates of open and laparoscopic pyeloplasty are similar, although laparoscopic pyeloplasty has not been performed for as long as the open procedure. The laparoscopic technique appears to be well tolerated by children and they seem to recover quickly.
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A very common use for laparoscopy is to detect the presence of an undescended testis that has not been able to be felt by the physician. In about 1 out of 5 boys with a testis that has not descended to the scrotum by 9 months of age the testis will not be able to be felt on examination. This may mean the testis is not present or that it is in the abdomen. It is very important to be sure of whether a testis is present or absent so that one is not left in the abdomen. This is to permit the best function of that testis, as well as reducing the risk of cancer in that testis developing without being detected. Some testes have descended into the scrotum, but have not grown well and are not functional. They are best removed.
It has been found that laparoscopy is an excellent way to determine where a testis is if it cannot be felt, and to help in moving a testis into the scrotum to permit the best growth and development possible for that testis. It is important to recognize that even with the testis being moved into the scrotum by surgery, it may not develop well due to it not having been a very good testis to begin with.
It has not been useful to use imaging tests such as ultrasound or CT scans to look for a testis that cannot be felt. If they can detect the testis, some form of surgery is needed, yet if they cannot see the testis, they are not reliable enough to avoid surgery. IN any event, some sort of surgical procedure will be needed. With laparoscopy, no further surgery is needed in some cases, and in others, the surgery is helped with the information as to exactly where the testis is. For more information, see undescended testes
Laparoscopy can then be used to bring a testis that is in the abdomen down to the scrotum. This requires three instrument ports and requires about 1 to 1 1/2 hours to perform and children may go home later that day or the next morning. In some cases where the testis is very high in the abdomen, it will not reach on its major blood supply which comes from the area of the kidney. In those situations, the major blood supply is closed using a surgical clip applied by the laparoscope. This allows the other blood supply to increase its capacity between the two procedures. The second procedure is performed between 4 and 6 months after the first stage. At this time the secondary blood supply is used to keep the testis alive, usually with excellent results.
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Laparoscopy for vesicoureteral reflux is being explored as a new alternative to the usual open surgery for reflux. Initial attempts were successful, but required a great deal of time to be performed and did not appear to have a substantial benefit. Recent techniques seem to be more efficient and have a reasonable success rate. This will need to be evaluated very carefully since the current success rate for open surgery is about 98%, with very few complications. For reflux on one side, this may be fixed with surgery that does not open the bladder and the recovery is rapid. Otherwise the hospital stay is about 3 days in most patients. It will need to be equally efficient for laparoscopic surgery for reflux. There is a much smaller scar caused with laparoscopic surgery also. The scar with open surgery is low in the abdomen and usually covered by underwear. Continued technical improvements in this method will likely provide good alternatives to open surgery.
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Percutaneous nephrolithotomy (PCNL) is a technique in which a needle is used to puncture the kidney under ultrasound or X-ray guidance and an instrument is passed into the kidney to allow direct examination, fragmentation and removal of a stone. This technique requires the patient to be completely asleep. A kidney drainage tube is usually left in place for 2 to 4 days, and removed in the office. PCNL is particularly useful in a patient with a hard stone that might not fragment with ESWL or in whom the anatomy of the kidney is not normal. In those children, fragmented stones may not pass effectively. If a stone has created a serious obstruction, a kidney drainage tube (nephrostomy) may have already been placed and this may be used to remove the stone. Stones may be removed using this technique all the way to t he bladder. In small children, the size of the tube used for access to the kidney must be adapted to the child's size. A special, small percutaneous access sheath has been developed here to permit access to the kidney for stone removal in small children. This system is very useful for small and moderate stones, but less so for large stone (>2.0 cm). Other techniques used involve obtaining access with a variety of methods. Most involve some sort of kidney puncture and dilation of the tract to permit Endoscopic treatment for VUR.
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Kidney stones are not common in children, but do occur and may present a difficult treatment problem. There are many minimally invasive methods for removing kidney stones, but few that are designed for children. Stones may cause problems anywhere in the urinary tract, from the kidney to the ureter and into the bladder. Most of the time they are in the kidney or ureter. They cause pain by creating an obstruction of the drainage of the urine. The muscles involved usually spasm somewhat, which causes the pain, but also helps the stone pass. Children can pass stones that are relatively large as compared to adults. At times, however, it is necessary to remove the stones; this is based on pain, nausea and vomiting, fever, or any other marked change in the child's condition that may be due to the stone. It is also appropriate to remove a stone that is growing so that it may be removed more easily, rather than waiting until it is very large.
The usual methods to remove a kidney stone in children include Extracorporeal shock wave lithotripsy (ESWL), percutaneous nephrolithotomy (PCNL), ureteroscopy, or open stone surgery. The choice of technique depends upon the location, size and type of stone, as well as the child's medical condition and anatomy. All methods are possible in children.
ESWL is also known as the "stone bath" because the initial machines that were used involved having the patient lie in a water bath to permit passage of shock waves. The method is based on focusing shock waves from a generator outside the body through the skin to reach the stone in the kidney or ureter. This is like focusing sunlight through a magnifying lens to create enough heat to burn. If you place your hand in the beam close to the lens it will not even feel warm as the light rays are not focused, but at the point where they are focused, they can burn paper. The shock waves are focused so that they are intense at the position of the stone, but are more spread out at the level of the skin and therefore do not do any damage to the skin. The positions of the stone and shock waves are controlled using ultrasound or X-ray guidance. Many shock waves are applied slowly, often several thousand, over about 20 minutes. In older children this may permit use of sedation to control discomfort, but in small children, general anesthesia is used. The entire procedure takes about 45 minutes to permit accurate positioning and focusing. The stone is fragmented and the pieces will pass over the following days. It may take up to 3 months for all fragments to pass, and this depends upon the position of the stone. The overall success rate of ESWL is about 85%. Stones in the lower pole of the kidney are less likely to pass. Very hard stones such as those made of cystine or certain kinds of calcium stones, may not fragment very well.
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The information on this website should not be taken as medical advice,
which can only be given to you by your personal health care professional. |
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Copyright © Children's Hospital Boston. All rights reserved. |
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