Les complications de la nephrectomie laparoscopique

Objectif: Depuis l'avenement de la chirurgie minimale invasive; la voie laparoscopique devient la reference pour le traitement chirurgical des pathologies renales. L'objectif de ce travail est d'analyser les complications de la nephrectomie laparoscopique. Patients et methodes: Les nephrectomies laparoscopiques realisees en 10 ans (1996 - 2005) ont ete revues. Les caracteres demographiques; les incidents per-operatoires et les complications post-operatoires ont ete etudies. Resultats: Il y avait 181 patients operes dont 83 nephrectomies radicales; 80 nephrectomies simples et 18 nephro-ureterectomies. L'age moyen est de 59 ans. Des antecedents de chirurgie et/ou de radiotherapie etaient observes chez 103 patients (56;91). Chez 25 patients (13;81); on notait au moins une complication. Une conversion etait necessaire chez 6 patients (3;31) avec 4 plaies vasculaires et 2 difficultes de dissection. Dans 10 cas (5;52); les complications etaient majeures (8 cas de saignements; 1 cas d'odeme aigu des poumons; 1 cas de fistule digestive) avec 2 deces. Chez 15 patients (8;29); elles etaient mineures avec 9 cas d'hematome; 3 cas d'infection parietale; 2 cas d'emphyseme sous cutanee et 1 cas d'eventration lombaire. Conclusion: Le taux global de complications est de 13;81. Il semblerait que l'existence de facteurs de risque associes (age avance; tares; antecedents chirurgicaux ou irradiation) augmente le taux de complication. Le profil de ces patients est un des elements a prendre en compte pour prevoir et prevenir ces complications

Laparoscopic retroperitoneal versus open nephrectomy in children: a comparative study

Nephrectomy, nephroureterectomy and heminephroureterectomy for congenital anomalies are common procedures in the pediatric urological practice. The use of laparoscopy in such procedures is claimed to be an excellent alternative to the classical open technique, and is rapidly becoming the gold standard, laparoscopy could be performed through either a transperitoneal or a retroperitoneal approach. The aim of this study was to compare the laparoscopic retroperitoneal nephrectomy technique in children with its open counterpart. Between August 2003 and August 2005; 13 cases [mean age 4.5 years [range 2-14 years]] were operated upon in our department using the laparoscopic retroperitoneal technique: four heminephroureterectomies [double system with or without ureterocele], four nephroureterectomies [two posterior urethral valves and two vesico-ureteric reflux cases] and five simple nephrectomies [one multicystic dysplasti kidney, one neglected uretero-pelvic junction obstruction, one pyonephrosis and two refluxing non functioning kidneys]. The procedure was performed using a 3-port technique [two 5mm and one 10 mm ports]. This peri and postoperative data of this group was compared retrospectively to a similar group of 10 patients who underwent open nephrectomies during the same period. The mean follow up was 9 months [range 4-18 months]. In the laparoscopic group, the mean operative time was 145 minutes [range 90-180 minutes] and no blood transfusion was needed. There was no need for intravenous analgesia except in one patient. Bowel movement was recovered between 6 and 8 hours [mean 7 hours] postoperatively. The drain was removed after 12 to 16 hours [mean 12 hours] and children were discharged after 24 to 36 hours [mean 24 hours]. One heminephroureterectomy was converted to an open technique [due to technical problems]. Two cases were completed by the transperitoneal route [one nephrectomy with previous percutaneous nephrostomy and one heminephroureterectomy] due to difficulty to create/loss of the laparoscopic retroperitoneal space. In the open surgery group, the mean operative time was 105 minutes [range 60-130 minutes] and no blood transfusion was needed. Intravenous analgesia was necessary in 8 children. Bowel movement was recovered 12 to 18 hours postoperatively [mean 12 hours]. The drain was removed 48 to 120 hours postoperative [mean 72 hours] and children discharged after 3 to 5 days [mean 3 days]. Laparoscopic retroperitoneal nepherectomy, nephroureterectomy and heminephroureterectomy in children are feasible, safe and provide an excellent alternative to open surgery. The retroperitoneal approach may even be superior to the transperitoneal approach; however, large numbered studies are needed to confirm this